medical commission 4shb1103 report to the governor and the

Washington State Medical Quality Assurance Commission

Efficient, Transparent, Responsive: a Safer Patient,

a Respected Profession, a Modern Medical Board

Fourth Substitute House Bill 1103 Pilot Project Report

Submitted to the Governor and the Washington State Legislature

December 2012

DOH 658-019

mtm1303

Typewritten Text

Washington State Medical Commission 4SHB1103 Report

2


3

Contents

Executive Summary………………….....……………………………………….….…………………5

Section 1: Accomplishments……………………………….………………………………………....7

The Commission Received National Recognition ….…………………………………….……….7

The Commission Enhanced Patient Safety………….………………………………………….….9

The Commission is More Transparent and Consumer Friendly………………………………….13

Section 2: Current Projects…………………….……………………………………………..….…15

Planning for the Future of Health Care………………….……………………………………….16

Section 3: Performance………………………....……………………………………………...……17

The Commission issued 99 percent of its licenses on time…………..………………………..…19

The Commission assessed 99 percent of complaints on time………………………………….....22

The Commission completed 90 percent of investigations on time…...……..…………………....24

The Commission eliminated its investigations backlog…………………………………………..25

The Commission’s investigation performance is consistent………….…………………………..26

The Commission eliminated 74 percent of the legal backlog………..…………………………...29

The Commission imposed consistent discipline……………………...…………………………..30

The Commission transferred 100 percent of sexual misconduct complaints on time…….......….31

Section 4: National Research………..………………………………………………………..…..…32

National Bureau of Economic Research…………………………………………………....…….32

Urban Institute…………………………………………………....………………………………32

Recidivism……………..…………………………………………………………………………33

Public Citizen………………….....……………………………………………………………….34

Section 5: Conclusions………….……………………………………………………………………35


4

Commission Members

Mark L. Johnson, MD, Mt. Vernon General Surgery Congressional District 1

Warren B. Howe, MD, Bellingham Family Medicine Congressional District 2

Leslie M. Burger, MD, Vancouver Internal Medicine Congressional District 3

Vacant Congressional District 4

Bruce G. Hopkins, MD, Spokane Obstetrics/Gynecology Congressional District 5

Mimi Pattison, MD, University Place Hospice and Palliative Care Congressional District 6

Ronald Schneeweiss, MBChB, Seattle Family Medicine Congressional District 7

William Gotthold, MD, Wenatchee Emergency Medicine Congressional District 8

Thomas M. Green, MD, Seattle Orthopedic Surgery Congressional District 9

Richard Brantner, MD, Olympia Emergency Medicine Congressional District 10

Bruce F. Cullen, MD, Redmond Anesthesia Physician at Large

Peter Marsh, MD, Lakewood Internal Medicine Physician at Large

Michelle Terry, MD, Seattle Pediatrics Physician at Large

Athalia Clower, PA-C, Pasco Family Practice Physician Assistant at Large

Ellen Harder, PA-C, Gig Harbor Family Practice Physician Assistant at Large

Michael Concannon, JD, Seattle Public Member

Jack Cvitanovic, Tacoma Public Member

Theresa Elders, LCSW, Colville Public Member

Frank Hensley, Olympia Public Member

Linda Ruiz, JD, Seattle Public Member

Mimi Winslow, JD, Seattle Public Member


5

Executive Summary

In Chapter 137, Laws of 2008 (4SHB 1103), the Legislature created a pilot project to evaluate

whether granting the Medical Quality Assurance Commission greater authority over its staffing and

budget would result in more timely, consistent and effective regulation of allopathic physicians (MDs)

and physician assistants (PAs). The data presented in this report shows the increased autonomy resulted in

more effective regulation of the complex, highly specialized work of allopathic physicians and physician

assistants.

The Medical Commission embraced the Legislative change and created a new organizational model,

reforming the Commission’s structure and streamlining its work. The Executive Director is now

appointed by, and is directly accountable to, the Commission. Under this model, the Commission’s staff

works as a co-located team, collaborating and supporting each other’s work on licensure, investigations,

discipline, compliance, education, outreach, and data analysis. The Commission developed expertise by

focusing exclusively on matters related to MDs and PAs and by addressing prominent issues such as

chronic noncancer pain management, office-based surgery and medical marijuana.

In the new model, investigators, attorneys and Commission members work as a team on complaints

from the public, medical professionals, hospitals, insurers, and other regulatory and law enforcement

authorities. The investigators, predominantly clinically trained nurses or PAs, use their professional

training to evaluate medical records and conduct interviews on the complex issues brought to the

Commission. Staff attorneys work closely with investigators and Commission members. The team of

investigator, staff attorney and Commissioner collaborate to craft resolutions to protect the public that are

medically and legally sound. This team approach eliminates the inefficiencies of “hand offs” and creates

ownership for each case, further motivating staff and Commissioners to arrive at appropriate resolutions.

The team model is responsive and able to keep pace with the rapidly evolving medical profession. The

Medical Commission’s new model contributed to national recognition, enhanced patient safety, superior

performance and increased transparency.


6

The Medical Commission received national recognition for its work:

• The Administrators in Medicine Best of Boards Award 2012 for Pain Rules Education;

• Improved from 44th to 9th in Public Citizen’s ranking of state medical boards.

The Medical Commission enhanced patient safety:

• Established rules governing the prescribing of opioids for chronic, noncancer pain;

• Developed a rule to protect the increasing number of patients undergoing office-based surgery;

• Created communication networks with stakeholder organizations to reduce medical errors.

The Medical Commission increased transparency:

• Crafted more clear, consistent, and transparent disciplinary orders;

• Increased awareness and deterrence by distributing disciplinary actions through a listserv and the Commission newsletter;

• Designated time for public input at Commission business meetings.

The Medical Commission improved performance in its licensing and disciplinary processes:

• 99 percent of licenses issued were within timelines, to more expediently and effectively meet the demand for qualified health care providers;

• 99 percent of complaints reviewed by the Commission were within timelines, guaranteeing rapid response to patient complaints and potential consumer safety issues;

• 92 percent of opened complaints were investigated within timelines in the last fiscal year;

• Investigation backlog eliminated;

• 92 percent of legal cases acted on within timelines in the last fiscal year;

• 99 percent of disciplinary orders complied with sanction rules, resulting in consistent discipline.

These accomplishments validate the Medical Commission’s new model and the pilot project.

The result is a safer patient, a respected profession, and a modern medical board.

The Medical Commission suggests the Governor and Washington State Legislature make permanent

the provisions of 4SHB 1103 with the enhancements detailed in Section Five: Conclusions. The

Commission extends its sincere appreciation to the Governor and the Washington State Legislature for

their trust, and to the Department of Health for its cooperation during this pilot project.


7

Section One: Accomplishments

The Medical Commission Received National Recognition.

Administrators in Medicine Best of Boards Award The Commission received the “Best of Boards Award” from the Administrators in Medicine (AIM) in

2012 for its education program during the implementation of the Pain Management Rules. The

Commission designed a comprehensive program to educate the medical profession and the public on the

requirements of the new rules and to assist practitioners in providing better pain care to patients.

The Commission is humbled to be the recipient of this highest, national honor from its peers.

Improved Public Citizen Medical Board Ranking Each spring, Public Citizen, a national consumer advocacy organization founded by Ralph Nader,

ranks state medical boards. The Commission improved its ranking from 44th to 9th during the pilot. Public

Citizen recognized the Medical Commission as one of the most improved states in its 2012 report.i

Public Citizen bases its annual board ranking on the number of serious disciplinary actions per 1,000

licensees over a three-year period.

39 42 41

45 44

38

23

18

9

1

6

11

16

21

26

31

36

41

46

51

2003 2004 2005 2006 2007 2008 2009 2010 2011

Washington State Medical Commission Public Citizen Board Ranking


8

In the report, Public Citizen recommends that medical boards will do a better job disciplining

physicians if the medical boards:

• Receive adequate funding (all money from license fees going to fund board activities instead of going into the state treasury for general purposes);

• Have adequate staffing;

• Engage in proactive investigations, rather than only reacting to complaints;

• Use all available/reliable data from other sources such as Medicare and Medicaid sanctions, hospital sanctions and malpractice payouts;

• Have excellent leadership;

• Are independent from state medical societies;

• Are independent from other parts of the state government.

Commissioners and Staff Honors, Awards, Appointments Individual members of the Commission and staff are highly engaged in national organizations to

improve medical regulation and patient safety on a national level. Honors, national awards, numerous

appointments, and recognition evidence this engagement. The Federation of State Medical Boards

recognized past Commission Chair Samuel Selinger, MD, with the John H. Clark Leadership Award in

2011. Mimi Pattison, MD, the current Chair of the Commission, was awarded the 2010 Sojourn award

from the Regence Foundation, Regence Health Plan. This award came with a $50,000 grant, which Dr.

Pattison donated to support a program for people with mental illness who need palliative medicine and

end-of-life care with the Franciscan Hospice and Palliative Care organization. Full details on other

honors, awards and appointments are listed in the appendix. (See Appendix A)

The Medical Commission Met and Exceeded its Performance Goals. The Commission streamlined processes to grant licenses faster, responded more quickly to complaints

about patient safety, and performed consistently across all performance measures. For complete details

please see Section Three of the report.


9

The Medical Commission Enhanced Patient Safety. The Commission proactively addressed prominent patient safety issues by setting standards in three

growing, high-risk areas of medicine, by creating patient-safety focused policies, and by working with the

medical profession to reduce medical errors. The authority granted during the Pilot Project allowed the

Commission to efficiently utilize staff to contribute to these significant improvements in patient safety.

Management of Chronic Noncancer Pain Rules This state and the nation faced what the Centers for Disease Control deemed an “epidemic” of

prescription opioid overdoses that were killing more Americans everyday than overdoses from heroin and

cocaine combined. Recognizing the critical and emergent nature of this issue, the legislature passed

Engrossed Substitute House Bill 2876 (ESHB 2876), which required the boards and commissions

regulating controlled substance prescribers to create rules that require consultation with a pain specialist

at a threshold dose. With the mandate created by this crisis and the direction the legislature provided, the

Commission led the workgroup that was assembled to create rules designed to stem the tide of tragic

prescription opioid deaths.

The Medical Commission members participating in the workgroup were key in developing rules that

were ultimately adopted, in nearly identical form, by all five of the boards involved. The rules

spearheaded by the Commission do require consultation with a pain specialist when opioid doses reach

dangerous levels. However, the rules go much further by creating a mandated framework that directs

physicians in providing safe pain care when opioids are used, from initial visit to discharge. In adopting

these rules, the Commission became the first state medical board in the nation to have rules that establish

minimum practice standards regarding chronic pain care for individual physicians. It is anticipated that

these rules, assisted greatly by the deployment of a prescription monitoring program, will save lives that

may have been lost due to the proliferation of prescription opioids. Since the statute (ESHB 2876) was

passed, the state has seen a 35 percent decrease in the number of opioid-related deaths.ii

The Commission delayed the effective date of these rules in order to develop and implement

a robust educational program. The educational program was designed to not only educate physicians

about the requirements of the pain rules, but by reaching out to them and addressing their questions and

concerns, the Commission sought to secure their compliance and calm fears that might lead them to

discharge or refuse chronic pain patients. The very extensive and personal outreach of this educational

program has proven very successful, as measured by the lack of cases alleging non-compliance, the

number of participants in the live presentations and in the on-line CME, and countless anecdotes from

individual providers who have appreciated this effort. The Commission earned a national award for the


10

pain rules educational program. In April 2012, the Administrators in Medicine (AIM) awarded its “Best

of Boards Award,” AIM’s highest honor, to the Medical Commission for this work. The following are

highlights of the Commission’s pain rules education program:

• Giving dozens of on-site presentations to more than 3,400 providers statewide;

• Developing a free, four-hour on-line Continuing Medical Education (CME) with the Agency

Medical Directors Group;

• Developing a web based opioid dosage calculator for use on smart phones and tablets

• Developing an interpretative statement explaining the intent of the rules, clarifying

misconceptions, providing guidance to the profession, and promoting access to care;

• Creating a pain management information brochure for patients;

• Sending a letter to all licensees providing information on the pain rules;

• Setting up a dedicated e-mail address for licensees and members of the public to submit

questions and receive individualized responses directly from the Commission;

• Designating a staff attorney as a subject champion for a personalized, single point of contact;

• Developing a comprehensive web page devoted to the pain rules with a section for frequently

asked questions and resources for patients, providers, and legal entities.iii

The Commission has received numerous testimonials and comments from practicing physicians and

physician assistants thanking the Commission for the framework and guidelines established by the pain

rules. These rules and their associated education efforts have resulted in a paradigm shift in Washington

regarding the treatment of pain and triggering a broader national conversation about appropriate opioid

usage. This is an area of practice that will undergo further evolution in the coming years and the

Washington State Medical Commission will be engaged in this process.

Office-Based Surgery Rule The Commission created a rule governing office-based surgery, establishing standards in a growing

and potentially dangerous area of medicine. The Commission now requires physicians to have their

offices accredited by a national accrediting entity. Recent publicized deaths in office-based practices

occurred in offices with no accreditation. The Commission requires physicians to ensure that someone

certified in advanced resuscitative techniques is present, that the physician can rescue a patient who goes

into a deeper level of sedation than intended, that a provider other than the surgeon monitor the patient,

and that the physician can transfer the patient to the hospital in an emergency.iv The Commission’s

regulations are a major step forward in enhancing patient safety in our state. The Georgia Composite

Board of Medicine used the Commission’s rule as a model for its own rule.v


11

Non-Surgical Medical Cosmetic Procedures Rules (Medi-Spas) The Commission established rules addressing the fast-growing medical spa industry, ensuring there is

adequate supervision over cosmetic procedures and that appropriately licensed and trained providers are

performing these procedures. This rule ensures that in this highly profitable industry, the safety of the

patient-- not profit-- is paramount.vi

Policies and Guidelines to Reduce Medical Errors The Commission developed two policies to work with the medical profession to reduce medical

errors. First, the Commission adopted a guideline on wrong-site surgery to require physicians who

perform wrong-site, wrong-procedure, or wrong-patient surgery to make a presentation to their peers,

explaining how the error was made and how to prevent the error from re-occurring.vii Second, the

Commission adopted a policy designed to prevent medical errors by providing summaries of actual

Commission cases involving systemic medical errors, with key learning components, to the Washington

State Hospital Association (WSHA). This communication of systemic problems and possible resolutions

to the WSHA makes this information available to all 97 Washington State hospitals to reduce medical

errors system-wide.viii These two policies reflect the conclusion of the Commission that peer-to-peer

education is the most effective method to reduce medical errors.

The Commission also adopted practice guidelines on the Transmission of Time Critical Medical

Information (TCMI). TCMI typically involves lab values, diagnostic tests, or pathology results that need

to be communicated to a physician so that the health of the patient is not adversely affected. The

guidelines communicate the importance of physicians collaborating to establish procedures for

transmitting TCMI to assure timely care and patient safety.ix

Finally, the Commission adopted a policy on Physicians Exhibiting Disruptive Behavior, i.e.,

behavior that negatively affects patient care and interferes with the ability to work as part of a care team.

In this policy, the Commission requests that organizations address this threat to patient safety by engaging

in early intervention of the disruptive physician to prevent patient harm. The Commission warns that it

considers this behavior a threat to patient safety and will take disciplinary action, including suspension, if

warranted.x


12

Commission Disciplinary Cases Communicate Standards and Influence Institutions The Medical Commission views its disciplinary function as more than just imposing sanctions on a

single physician. Through discipline, the Commission communicates standards and expectations to the

individual disciplined and to the entire profession. Individual physicians and institutions most often

respond to disciplinary action with improved practices. What follows are two recent examples where

Commission action led to known institutional or industry improvement:

The Commission addressed the growing and dangerous practice of physicians prescribing human

growth hormone for anti-aging purposes. In 2010, the Commission disciplined a physician for this

practice, setting forth the particular conditions and requirements that must be met before prescribing this

dangerous hormone. In taking this action, the Commission was recognized as one of three state medical

boards that have taken leadership action, which resulted in publicized standards for prescribing human

growth hormone.xi

In another case, the Commission’s action led to improvements in the internal communication protocol

at a major Seattle hospital. The hospital’s credentialing committee was aware that a surgeon, to whom

they granted privileges, had performed a wrong-site surgery at a prior hospital. However, when that same

surgeon subsequently performed a second wrong-site surgery, internal protocol did not direct the

credentialing committee to inform the peer review committee about the previous event. The peer review

committee therefore did not recommend action due to the misperception that this was an isolated

incident. Because of the Commission’s investigation and disciplinary action, the hospital recognized and

remedied this communication gap, leading to better provider oversight and patient protection.


13

The Medical Commission is More Transparent and Patient Friendly.

The Medical Commission firmly believes that increasing transparency increases accountability and is

an important step toward improving patient safety.

The Medical Commission made a focused effort to make its disciplinary orders—the most visible

aspect of its work—more clear, consistent and transparent. The Commission made a focused effort to

issue orders that are written to be understandable to a member of the public. First, in 2008 the

Commission added a section to its orders explaining how the Commission determined what sanctions

were necessary to protect the public and protect their safety by preventing reoccurrence. This section also

explains how the sanctions comply with the sanction guidelines (now rules) that were created to maintain

consistency among orders. The order then lists the mitigating and aggravating factors to determine the

length of monitoring and other sanctions necessary to protect the public. This change made the

Commission’s decision-making more transparent to the public. The Department of Health adopted this

approach and it is now part of the sanction rules. Second, the Commission made an effort to use

consistent language in orders, particularly in stating the status of the license. Third, the Commission

created headings in bold for each sanction to make orders easier to navigate. A major health insurer

thanked the Commission for improving the clarity of its orders. (See Appendix K)

The Medical Commission created a listserv to quickly and efficiently inform the public of its legal

actions. Twice each month, the Commission sends a list of its orders and statements of charges to

members of the public, media, health care systems and other interested parties via the listserv.xii

The Commission takes every opportunity to promote the service to potential subscribers, many of whom

depend on the information to make decisions for their organizations.

The Medical Commission re-launched its newsletter in 2011. The budget authority granted by 4SHB

1103 allowed the Commission to employ this very effective tool. The newsletter is a medium for the

Commission to communicate with the entirety of the provider population it regulates. This quarterly

publication addresses topics such as enhancements to Commission services, future trends in medical

practice, meeting schedules, and disciplinary actions. The newsletter is mailed to all MD and PA licensees

and posted on the Commission’s website. The Commission created a newsletter listserv for digital

distribution of the publication in anticipation of going to paperless production in the near future.


14

The Medical Commission is proactive in educating health professionals in Washington.

The Commission greatly expanded its education program during the pilot. The Commission made

presentations to nearly every county medical society in the state, staffed an educational booth and

provided a pain rules update at the state medical society annual meeting. The Commission made dozens

of presentations to over 3,400 health professionals to educate the profession on the pain rules. The

Commission collaborates with stakeholder organizations on web trainings, which are recorded and

accessible on demand on the Commission web site. Finally, the Commission created a Speakers Bureau to

facilitate stakeholder and public requests for education. The Speakers Bureau has a dedicated web page,

email, suggested presentation topics, and speaking request form.

The Medical Commission encourages public input at its meetings. In the interest of obtaining more

input from the public, the Commission established time at its business meeting to invite members of the

public to provide input and a public perspective on the Commission’s work. The Commission also

engages in dialogue with members of the public at its policy committee meetings.

The Medical Commission implemented 2011 Substitute Senate Bill (SSB) 1493, the transparency

bill. The Commission enhanced its process of working with complainants who request that the

Commission reconsider its decision to close a complaint. The Commission also developed a procedure to

encourage complainants to provide details on the impact of a practitioner’s conduct.

The Medical Commission is more responsive to complainants. The Commission recently implemented

a practice to inform complainants of the completion of the investigation, and of the specific progress of

the complaint as it moves through the legal process.


15

Section Two: Current Projects

The Commission continues work to enhance patient safety.

Demographics With the help of the Legislature passing SSB 5480 in 2011, the Medical Commission now collects

demographic information from licensees for the purposes of workforce planning. This data will help

stakeholders in many ways, including addressing physician shortages, emergency planning, research, and

assisting county medical societies with patient referral data. The Commission worked closely with the

National Center for Health Workforce Analysis Director Ed Salzburg at the Health Resources and

Services Administration to harmonize its census with the federal minimum data set. The most recent

demographics report is located in the appendix. (See Appendix D)

Annual Medical Commission Workshop/Conference Every year the Medical Commission meets for two days to educate the Commission members, staff,

and interested parties on topics of relevance to the Commission and medical regulation. This workshop

model has served the Commission well as a forum to work on difficult policy issues or hear from

nationally known speakers. At the workshop in 2011, aviation expert John Nance, author of Why

Hospitals Should Fly, spoke about how aviation safety principles can be applied to improve patient safety

in hospitals. In 2012, the Commission successfully transitioned from the workshop model to the

educational conference model. Attendees came from across Washington, and the presenters were

nationally and internationally known experts in their fields.xiii Topics included patient safety, the latest

opioid research, social media and professionalism. The Commission plans to expand the offerings for the

conference in coming years as a public service to all licensees, the public and other interested parties.

Board-to-Board Discussions In an effort to gain perspective outside the organization and exchange best practices, the Medical

Commission began a program called Board-to-Board. This is a scheduled call between the Commission

and other state medical boards with a discussion guide and fact sheet distributed in advance. The Board-

to-Board discussions helped the Commission to become more efficient in its processes, including

modernizing licensure requirements, reforming its expert witness program, and revising its structure. (See

Appendix B)


16

The Medical Commission Plans for the Future of Health Care.

The Medical Commission continues to seek ways to become more efficient, transparent and responsive

in order to enhance patient safety. The Commission’s future plans include:

• Proposal to the Legislature to update the licensing requirements to reflect current medical training standards, attract qualified practitioners to Washington, and address existing and projected shortages;

• Reforming and enhancing the expert witness program;

• Modernize Commissioner Information Technology business tools to current professional standards, which will streamline and make more efficient how the Commissioners do their work;

• Developing guidelines on the use of social media by physicians and physician assistants;

• Tracking national telehealth and telemedicine trends, and develop new guidelines or rules to facilitate the expansion of telemedicine to address shortages while ensuring patient safety and medical quality;

• Working with the medical profession to discern and implement the most effective intervention for physicians with disruptive behavior;

• Continuing teleconferences with sister boards to share best practices;xiv

• Conversion of all core business functions to paperless, and automation of functions.


17

Section Three: Performance The Medical Commission collaborated with the Nursing Commission (NCQAC) and the Department

of Health to develop performance measures in the areas of credentialing, discipline, human resources, rule

making, and budget. The pre-pilot period runs from fiscal years 2004 through 2008. The Pilot Project

period runs from fiscal years 2009 through 2012. The Commission incorporated these measures into its

strategic plan, which is updated every 18 months. The Commission improved its performance in all

measures during the Pilot Period. The Medical Commission performed highest in eight of the eleven

performance measures relating to licensing and discipline. Highlights include:

• 99 percent of completed applications were issued licenses within 14 days;

• 92 percent of investigations were completed within timelines in 2012;

• Eliminated the investigation case backlog;

• 99 percent of disciplinary orders complied with the sanction rules;

• 74 percent of the legal backlog was eliminated;

• 92 percent of legal cases were completed within timelines in 2012;

• 100 percent of sexual misconduct cases were transferred within timelines.

These performance improvements occurred with more complex license applications and discipline

cases, with licensees who have the highest rate of legal representation, do not have a duplicate license,

and rarely default or walk away from their licenses.xv

The hypothesis tested by the pilot projects in 4SHB 1103 is that greater Commission autonomy will

result in more efficient, effective regulation of healthcare professionals. A comparison of the Medical

Commission with non-pilot disciplinary authorities before and during the pilot period suggests that, with

respect to the Medical Commission, the hypothesis is true. Many factors contributed to the Commission’s

pilot project success. Perhaps the most significant distinction afforded by 4SHB 1103 autonomy is the

Commission’s ability to design a fully integrated business model where investigators and staff attorneys

work side-by-side, dedicated to Commission work alone, and develop the expertise necessary to regulate

the complex multi-specialty medical profession. The performance measures that follow illustrate the

success of the Commission’s model and of the pilot project created by 4SHB 1103. Full descriptions of

the measures and summary of the data by the Medical Commission may be found in the Appendix. (See

Appendix E)


18

Credentialing

The Medical Commission’s licensee population has grown 21 percent since 2004 and 10 percent

during the pilot. There have been no staff increases in the credentialing unit during the pilot.

The Medical Commission’s credentialing process became more consistent and efficient after the

Commission adopted the Federation of State Medical Boards (FSMB) Credentials Verification Servicexviii

xvi,

the FSMB Uniform Applicationxvii, and Veridoc for automated license verifications. Online renewals

for the medical profession began in September 2012. All of these improvements allow Commission

credentialing staff to focus on quality control and specialization as opposed to data entry and tasks related

to file tracking for dozens of professions.

23684 24071

24886

25883

26694

26063

27933 28408

28730

23000

25000

27000

29000

2004 2005 2006 2007 2008 2009 2010 2011 2012

Licensee Population


19

The Commission issued 99 percent of its licenses on time.

The Medical Commission maintained a performance of 99 percent or better for the last two fiscal

years. The Commission excelled in this measure because it established an internal credentialing unit with

control over 95 percent of credentialing functions. The credentialing unit is highly effective because staff

understands and takes ownership of the entire credentialing process, not just certain functions. The target

performance in this measure is 95 percent.

Measure 1.1: Health care credentials issued within 14 days of receiving all documents.xix

20%

30%

40%

50%

60%

70%

80%

90%

100%

FY09 FY10 FY11 FY12

Licenses Issued Within Timelines

Target

Secretary

HSQA

MQAC

NCQAC


20

The Commission denied 100 percent of unqualified applicants on time in the

last two fiscal years and exceeded the performance target during the pilot

period.

The Medical Commission has improved its performance in this measure each year, achieving 100

percent performance in the last two fiscal years. The Commission has maintained the highest overall

performance in this measure. This is due to good communication between the Commission’s credentialing

manager and legal unit manager. They meet twice a month to discuss non-routine applications. The target

in this performance measure is 83 percent.

Measure 1.2: Percent of applications in which a notice of decision on application is issued within 30

days of the decision of the disciplinary authority to deny the license or grant with conditions.

0%

20%

40%

60%

80%

100%

FY09 FY10 FY11 FY12

Notices of Decision Issued Within Timelines

Target

HSQA BC

Secretary

MQAC

NCQAC


21

Discipline: Complaints

The number of complaints received against MDs and PAs increased 20.5 percent during the pilot. There

have been no staff increases in the complaint intake process.

1043 1029 1018

1129 1165 1151

1222

1429 1404

900

1000

1100

1200

1300

1400

1500

2004 2005 2006 2007 2008 2009 2010 2011 2012

Growth in Complaints


22

The Commission assessed 99 percent of complaints on time.

Since the pilot began, the Medical Commission meets the timeline 99 to 100 percent of the time. The

Commission’s high performance is due to regaining control over the complaint intake process in 2008.

Since that time, the Commission assesses and decides whether to investigate a complaint within timelines

99 percent or better in this measure. The target performance in this measure is 77 percent.

Measure 2.1-Percent of cases in which the intake and assessment steps are completed within 21

days.

50%

60%

70%

80%

90%

100%

FY04 FY05 FY06 FY07 FY08 FY09 FY10 FY11 FY12

Complaints Assessed within 21 days

Target

Secretary

HSQA

MQAC

NCQAC


23

Discipline: Investigations

Since the beginning of the Pilot Project, the number of investigations has increased 15 percent. The

Commission added one part-time, non-clinical investigator to the investigations unit in fiscal year 2011.

775

702

769

871 882

940

878

1018 1015

600

650

700

750

800

850

900

950

1000

1050

2004 2005 2006 2007 2008 2009 2010 2011 2012

Growth of Investigations


24

The Commission completed 90 percent of investigations on time.

The Medical Commission immediately increased its performance with the start of the Pilot Project in

fiscal year 2009. In fiscal year 2012, the Commission completed 92 percent of its investigations within

timelines. The Medical Commission has the highest performance for the measure and is the only

disciplinary authority to consistently exceed the target. The Medical Commission is the only disciplinary

authority to improve in this measure between the pre-pilot and pilot periods.xx The goal is to perform

higher than the target of 77 percent.

Measure 2.2-Percent of cases in which the investigation step is completed within 170 days.

30%

40%

50%

60%

70%

80%

90%

100%


Investigations Completed within 170 days

Target

Secretary

HSQA

MQAC

NCQAC


25

The Commission eliminated its investigations backlog.

The Medical Commission dramatically reduced the investigations backlog in the first year of the Pilot

Project and effectively eliminated it by the end of fiscal year 2011. In this measure, the goal is to reduce

the backlog lower than the target of 23 percent.

Measure 2.4: Percent of open cases currently in the investigation step that are over 170 days.

0%

5%

10%

15%

20%

25%

FY09 FY10 FY11 FY12

Backlog: Investigations older than 170 days

Target

MQAC


26

The Commission investigation performance is consistent.

The Medical Commission has turned in the best performance in the Department of Health for this

measure. Note that fiscal year 2009 is not in this graph because some entities did not track this measure

until fiscal year 2010. In this measure the goal is to reduce the backlog below the target of 23 percent.


0%

10%

20%

30%

40%

50%

60%

70%

Q1

FY 1

0

Q2

Q3

Q4

Q1

FY11 Q

2

Q3

Q4

Q1

FY12 Q

2

Q3

Q4

Cases in Investigations Over 170 Days

MQAC

NCQAC

HSQA Boards andCommissions

Secretary


27

Discipline: Case Disposition

Since the Pilot Project began, the number of cases annually completing the case disposition step has

increased 30 percent. There have been no staff increases in the legal unit.

744 708 720

921

851

1046

891

995

1108

600

700

800

900

1000

1100

1200

2004 2005 2006 2007 2008 2009 2010 2011 2012

Growth in Case Disposition


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The Commission completed 92 percent of legal steps on time in 2012.

The Medical Commission’s integrated legal unit is highly efficient in resolving cases. The

Commission has shown marked improvement in the last three years, culminating in completing this step

on time in 92 percent of the cases in fiscal 2012. There are three reasons for this. First, the Commission’s

model creates an environment conducive to efficiency. Staff attorneys and investigators literally work

side-by-side, working with Commissioners as a team, improving communication and collaboration on

complex cases. Second, the Commission created a new procedure designed to ensure that cases are

presented in a timely fashion.xxi Third, the Commission created an early review and consent agenda for

closing cases, making meetings more efficient. The Medical Commission has the best performance of the

four disciplinary authorities in this measure during the Pilot Project. In this measure the goal is to perform

higher than the target of 77 percent.

Measure 2.3: Percent of cases in which the case disposition step is completed within 140 days.

60%

65%

70%

75%

80%

85%

90%

95%

100%


Case Disposition Completed within 140 Days

Target

Secretary

HSQA

MQAC

NCQAC


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The Commission eliminated 74 percent of the legal backlog.

The Medical Commission reduced its legal case backlog from 119 cases to 32 cases during the Pilot

Period. The Medical Commission has seen a drop in this measure, from over 40 percent to 20 percent,

which was a first for all disciplining authorities being compared. The Commission did not add staff

attorneys during the Pilot Period. The Commission recognizes that this backlog is still too large and is

continually working to reduce it further. In this measure the goal is to reduce the backlog lower than the

target of 23 percent.

Measure 2.5: Percent of open cases currently in the case disposition step that are over 140 days.

0%

10%

20%

30%

40%

50%

60%

70%

Q1

FY10 Q2

Q3

Q4

Q1

FY11 Q2

Q3

Q4

Q1

FY12 Q2 Q3

Q4

Cases in Case Disposition Over 140 Days

MQAC

NCQAC

Other HSQA Boards andCommissions

Secretary


30

The Commission imposed consistent discipline: 99 percent of Commission orders complied with the Sanction Rules.

The graph shows that once the Sanction Rules were in place in January 2010, the Medical

Commission complied with the Sanction Rules in 99.2 percent of its orders. This is the highest rate of

compliance for all of the disciplinary authorities. This is the result of the Commission’s effort to make its

orders clear, consistent, and transparent.

Measure 2.6: Percent of Orders and Stipulations To Informal Disposition (STIDs) that comply with

the sanction schedule.

65%

70%

75%

80%

85%

90%

95%

100%

2007 2008 2009 2010 2011 2012

Compliance with Sanction Schedule Guidelines/Rules

DOH Secretary

MQAC

NCQAC


Target


31

The Commission transferred 100 percent of sexual misconduct complaints on

time.

The Medical Commission recognizes the importance of processing sexual misconduct complaints and

transferred 100 percent of its non-clinical sexual misconduct cases within one day of the decision, well

within the 14-day timeline. The Commission works well with the Secretary of Health staff to ensure

seamless transfer of cases, including cases that are transferred back to the Commission when clinical

issues arise.

The Commission excelled in other performance measures.

The Medical Commission also excelled in performance measures covering human resources, rule

making, and budget. The Commission completes employee performance evaluations on time, adopted the

pain management rules on time, and kept within its allotted budget during the pilot period. Full

performance details can be found in the Appendix. (See Appendix E)

Performance Conclusion

The Medical Commission’s dedicated, focused and integrated business model performed at a higher

level during the Pilot Project than during the pre-pilot period, when the Commission staff were spread out

in pooled, functionalized units and not dedicated to the work of the Commission. The Medical

Commission excelled in the pilot and performed more consistently through internal business innovations

and with no staff increases in licensing or discipline.xxiii

xxii The Medical Commission is pleased with its

aggregate performance of 94.6 percent and is thankful to the Governor and the Washington State

Legislature for placing their trust in the Medical Commission during this pilot.


32

Section Four: National Research

4SHB 1103 required the Commission to review summaries of national

research and data regarding regulatory effectiveness and patient safety.

National Bureau of Economic Research Paper on Medical Board Discipline The National Bureau of Economic Research issued a paper entitled “Medical Licensing Board

Characteristics and Physician Discipline: An Empirical Analysis,” in 2009. In this paper, two economists

studied the relationship between the characteristics of medical boards and the frequency of discipline.

Specifically, the authors analyzed the effect of organizational and budgetary independence, public

oversight, and resource constraints on rates of physician discipline.

The authors concluded that medical boards with greater resources and greater organizational

autonomy had higher rates of discipline. The authors state that these findings are broadly consistent with

theories of regulatory behavior that emphasize the importance of autonomy for effective regulatory

enforcement.

These findings are consistent with the Commission’s improvement in the pilot project and the

increase in national board ranking by Public Citizen.

The Urban Institute Study In February 2006, a case study report was published concerning the discipline of physicians. The

study, conducted by Randall Bovbjerg of the Urban Institute on behalf of the U.S. Department of Health

and Human Services, examined six case study states, including Washington. Two years after publication

of the U.S. Department of Health and Human Services-Urban Institute report, the Medical Commission

created its dedicated and integrated model for the Pilot Project. This model addressed some of the budget,

staffing, and sanction consistency impediments listed in the report.

The report noted effective practices for improving complaint-based discipline:

• More effective intake and triage of complaints;

• Tracking of trends in malpractice and “below threshold” cases to direct proactive discipline;

• Enhancements to staff capacity relating to investigation and case oversight;

• Improved access to medical expertise throughout the disciplinary process;

• Maintaining regulatory autonomy;

• More modern information technology;


33

• Reducing “handoffs” by creating unified teams to handle cases;

• More centralization of case oversight to reduce fragmentation of responsibility;

• Standardization of sanctions to improve consistency;

• More active leadership;

• Additional budgetary resources;

• Develop proactive pathways to discipline and remediation through collaboration with health

care stakeholders, to address potential practice issues before there is harm;

• Develop internal reviews of cases and conduct self-evaluations on the Board.

Structural factors identified in this report as enablers to disciplinary performance:

• More funding and unrestricted access to the full budget allotment;

• More public Board members;

• More professional staff;

• A team approach throughout the discipline process;

• Investigators dedicated to medical investigations;

• Database systems that are specialized to the needs of the Board;

• Independence from state medical societies and other parts of government;

• Broader authority, sanctions;

• Move to a “sunset review” system.

The Commission feels an updated analysis is needed to determine if the changes made as a result of

the Pilot Project are effective in addressing the impediments listed in the 2006 report. The Medical

Commission received a grant to conduct a small-scale follow up of the 2006 study on physician

discipline. The Urban Institute will provide the follow up report in early 2013.

Recidivism In 2007, the Journal of Health Politics, Policy and Law published a study entitled “Sanctions and

Recidivism: An Evaluation of Physician Discipline by State Medical Boards.”xxiv The authors studied data

from 1994-2002 to discern how often physicians disciplined in the past receive discipline in the future.

The authors found that 9.6 percent of physicians disciplined in the time period 1994 to 1998 were

disciplined again in the time period 1999-2002.

The Commission studied its recidivism rate for the time period 2004 to 2012 and found it to be nine

percent. The Commission’s rate is below the national rate, though it is from a different time period. The

Commission believes its relatively low recidivism rate is due to its comprehensive compliance program.

A compliance officer monitors each practitioner for the duration of the order. An investigator conducts


34

practice reviews on-site during the compliance period. In some situations the Commission mandates a

preceptor for the practitioner under compliance. The strongest component of this program is the

requirement for each practitioner under formal discipline to appear personally before the Commission

periodically to demonstrate compliance with the order. The Commission currently monitors 181

practitioners. In fiscal 2012, 60 practitioners personally appeared before the Commission and 48

successfully completed their compliance programs. As of July 2012, the Washington Physicians Health

Program monitored 248 physicians and physician assistants, 24 of those are mandated into the program

by the Commission. The Commission is the only disciplinary authority in Washington that requires

personal appearances as a standard component of discipline.

Public Citizen-Hospital Actions In 2011, Public Citizen published a study on the relationship between hospital privileging actions and

the lack of subsequent medical board disciplinary actions.xxv Public Citizen asked 32 state medical boards

to provide data on the reasons the board failed to take disciplinary action against physicians who have had

their hospital privileges restricted or terminated. The Medical Commission analyzed data on hospital

actions over the past ten years and provided the requested information. Public Citizen told the

Commission it provided one of the best responses.

In participating in the Public Citizen study, the Commission learned how to improve further.

First, not all hospitals or clinics were reporting privileging actions to the Commission. The Commission

wrote to the facilities that failed to report actions to the Commission inquiring about the failure to report.

The Commission also wrote to all 97 hospitals in Washington State, reminding them of their obligation to

report hospital-privileging actions to the Commission. Second, the Commission did not always document

the reason for not taking action in a particular case. The Commission now documents the rationale for the

closure of each case in the file. This project helped the Commission to improve transparency, improve

accountability and improve patient safety.


35

Section Five: Conclusions

The Washington State Medical Commission dramatically improved by every established metric.

From performance efficiency and transparency, to engaging with the medical profession to enhance

patient safety, the Commission embraced the challenge of self-improvement through positive

organizational change at every level. This improvement has been recognized by our stakeholders across

the region and nationally by our peers and critics alike. The Commission’s ability to address complex

professional health and safety issues will continue to generate public awareness and national recognition.

The Medical Commission’s performance and accomplishments over the past five years is directly

related to the thoughtful autonomy granted in 4SHB 1103. This legislation enabled the Commission to

organize its staff into an interdisciplinary team and establish a productive work environment, which

developed attitudes of ownership and collaboration. The Commission’s model of a dedicated and

integrated work environment will continue to foster shared values and collaboration among its personnel,

enabling the Commission to remain at the forefront of modern medical boards. By integrating licensing,

investigative, legal, compliance, administrative, data, and policy operations the Commission created a

model that can effectively respond to complex medical issues facing public health and the medical

profession.

The Washington State Medical Commission will continue to become more efficient, transparent and

responsive, effecting positive change to promote patient safety and enhance the integrity of the

profession.

Solutions for Success The Medical Commission looks forward to continuing to work in partnership with the Department of

Health, the medical profession, and health care organizations to better protect the public and enhance

patient safety in our state. To accomplish this work the Commission suggests the following:

Make permanent the provisions of 4SHB 1103 with the following enhancements:

• Establish direct accountability. The Commission will submit a report at the end of each fiscal

year summarizing its licensing and disciplinary activity and will undergo

a sunset review every five years. The Commission is committed to continually assessing its

structure and performance to become more efficient, transparent and responsive. The public and

the profession of Washington benefit from a Commission structure that has the authority to

continue improved performance. The Medical Commission will be directly accountable to the

Governor and the Legislature.


36

• Increase budgetary autonomy. The Pilot Project provided the Medical Commission with more

control over its budget. By law, the commission is fee supported. The 2011-13 Biennium

Cumulative Fee Revenue Report indicates the commission is at 99 percent of expected revenue.

Program expenditures have remained within allotment throughout the pilot. The commission and

its leadership have actively participated with the executive director in the development and

review of biennium budgets and supplemental decision packages. Decision Packages approved by

the Legislature from July 1, 2008 to June 30, 2012 funded:

o Retention of staff to maintain the legal workforce identified by the 2006 audit staffing

model;

o Addition of a full time management analyst position to manage data collection and

analysis of performance measures identified by the department and the commission and

to conduct national research and determine performance outcomes for the 4SHB 1103

report mandated by the Legislature;

o Addition of two full time employees to support the legislative mandate to implement a

survey sent to all physicians and physicians assistants at the time of renewal in order to

collect, analyze and disseminate demographic workforce information; and

o Education efforts of the commission to develop a quarterly newsletter and other

educational tools for distribution to health care providers, the public and other

stakeholders. The Commission suggests full authority and access to its budget and reserves within legal

requirements, not dependent on a legislative schedule. 4SHB 1103 granted additional authority to

the Commission to access budgetary reserves when needed. This reality of this provision was

nothing more than a second budget request process tied to the legislative schedule. The

Commission believes the intent of the Legislature was not met for this provision and suggests a

process be established to access reserve funds on an as-needed basis.

• Establish direct communication with the Office of Financial Management (OFM). The

Commission suggests a single, direct point of contact in OFM for budget and legislation requests.

This model of communication currently exists as a pass-through for budget matters. The

Commission suggests that the same model be applied to the request-legislation process. Budget

decision packages and legislation requests will require only the approval of the Commission in a

public meeting to be submitted for consideration by the Governor.

• Change the name. The public and the medical profession will better recognize the Commission’s

role as the state medical board with the name, Medical Commission of Washington (MCW).


37

i Public Citizen’s Health Research Group Ranking of the Rate of State Medical Boards’ Serious Disciplinary Actions, 2009-2011, May 17, 2012, Sidney M. Wolfe, M.D., Cynthia Williams, Alex Zaslow. ii See Appendix I for data on reduced deaths in Washington since 2010. iiihttp://www.doh.wa.gov/LicensesPermitsandCertificates/MedicalCommission/MedicalResources/PainManagement.aspx iv http://apps.leg.wa.gov/WAC/default.aspx?cite=246-919-601 vhttp://medicalboard.georgia.gov/sites/medicalboard.georgia.gov/files/imported/GCMB/Files/OBS%20Guidelines.pdf vi In 2010, the Commission set standards for licensees who inject medication or substances for cosmetic purposes or using prescription devices for cosmetic purposes. The rules require physicians to, among other things, take a history, perform a physical exam, obtain informed consent, to delegate procedures only to ARNPs, PAs and RNs, and to provide adequate supervision. http://www.doh.wa.gov/Portals/1/Documents/3000/CR-103P-5-5-2010.pdf vii Preventing Wrong-Site, Wrong-Procedure, Wrong-Person Surgery, MD 2011-08, September 30, 2011. http://www.doh.wa.gov/Portals/1/Documents/3000/MD2011-08%20Preventing%20Wrong%20Site%20Surgery%20%28signed%29%20.pdf viii Reducing Medical Errors: Developing Commission Case Studies for Hospitals and Other Entities, MD 2012-04, February 24, 2012. http://www.doh.wa.gov/Portals/1/Documents/MD2012-04.pdf ix Transmission of Time Critical Medical Information, Medical Commission. Medical Commission policy 2011-05, September 30, 2011; http://www.doh.wa.gov/Portals/1/Documents/3000/MD2011-05%20TCMI%20Adopted%209-30-11.pdf x Practitioners Exhibiting Disruptive Behavior. Medical Commission policy 2012-01, February 24, 2012; http://www.doh.wa.gov/Portals/1/Documents/3000/MD2012-01%20Practitioners%20Exhibiting%20Disruptive%20Behavior%20(signed).pdf xi “State Medical Board Actions and the Standard of Care for Prescribing hGH,” William J. Stilling, RPh, M.S., J.D., e-Journal of Age Management Medicine, Legal Briefs, April 2010. http://www.agemed.org/AMMGejournal/April2010/LegalBriefsApril2010.aspx xii This listserv provided timely information to persons and entities that rely on the Commission’s work to make important decisions on such things as hospital privileges and participation on health insurance panels. xiii Agenda, links to presentations, and biographies for the 2011 and 2012 workshops may be found in Appendix C. xiv See Board-to-Board section in Appendix B. xv Details on default orders, duplicate cases, and representation of medical cases may be found in Appendix G. xvi The Federation of State Medical Boards’ Federation Credential Verification Service establishes a permanent, lifetime repository of primary-source verified core credentials for physicians and physician assistants. The FCVS keeps a record of everything from medical diplomas to passports so that physicians and physician assistants do not have to go through the time and effort of assembling and forwarding this information every time they need to be licensed or credentialed. http://www.fsmb.org/fcvs.html xvii The Uniform Application for Physician State Licensure (UA) is a Web-based application that standardizes, simplifies and streamlines the licensure application process for physicians. Physicians fill out the UA online application once, and then use the application whenever they apply for licensure in another state that accepts or requires the UA for the rest of their careers. http://www.fsmb.org/ua.html

http://www.doh.wa.gov/LicensesPermitsandCertificates/MedicalCommission/MedicalResources/PainManagement.aspx

http://www.doh.wa.gov/LicensesPermitsandCertificates/MedicalCommission/MedicalResources/PainManagement.aspx

http://apps.leg.wa.gov/WAC/default.aspx?cite=246-919-601

http://medicalboard.georgia.gov/sites/medicalboard.georgia.gov/files/imported/GCMB/Files/OBS%20Guidelines.pdf

http://medicalboard.georgia.gov/sites/medicalboard.georgia.gov/files/imported/GCMB/Files/OBS%20Guidelines.pdf

http://www.doh.wa.gov/Portals/1/Documents/3000/CR-103P-5-5-2010.pdf

http://www.doh.wa.gov/Portals/1/Documents/3000/MD2011-08%20Preventing%20Wrong%20Site%20Surgery%20%28signed%29%20.pdf

http://www.doh.wa.gov/Portals/1/Documents/3000/MD2011-08%20Preventing%20Wrong%20Site%20Surgery%20%28signed%29%20.pdf

http://www.doh.wa.gov/Portals/1/Documents/MD2012-04.pdf

http://www.doh.wa.gov/Portals/1/Documents/3000/MD2011-05%20TCMI%20Adopted%209-30-11.pdf

http://www.doh.wa.gov/Portals/1/Documents/3000/MD2011-05%20TCMI%20Adopted%209-30-11.pdf

http://www.doh.wa.gov/Portals/1/Documents/3000/MD2012-01%20Practitioners%20Exhibiting%20Disruptive%20Behavior%20(signed).pdf

http://www.doh.wa.gov/Portals/1/Documents/3000/MD2012-01%20Practitioners%20Exhibiting%20Disruptive%20Behavior%20(signed).pdf

http://www.agemed.org/AMMGejournal/April2010/LegalBriefsApril2010.aspx

http://www.fsmb.org/fcvs.html

http://www.fsmb.org/ua.html


38

xviii Veridoc expedites the process of verifying the status of a physician's medical license. Physicians who hold one or more medical licenses in the United States and need to have verification of their licensure status sent to another state medical or osteopathic board can use this service. https://www.veridoc.org/overview.aspx xix Due to a change in the licensing database in 2008, only date from 2009 is available for the licensing measures. xx Please see Appendix E for aggregate performance tables for all compared groups. xxi Processing Completed Investigations More Efficiently, MD 2011-07, June 3, 2011. http://www.doh.wa.gov/Portals/1/Documents/3000/MD2011-07.pdf . xxii See Appendix E. xxiii The aggregate performance for fiscal year 2012 is calculated by taking the total potential performance of percentage based performance measures and dividing by the actual Medical Commission performance in those measures. In fiscal year 2012 potential performance totaled 900 and Commission performance totaled 851. Please see Appendix F for detailed discussion of aggregate performance and case timelines. xxiv “Sanctions and Recidivism: An Evaluation of Physician Discipline by State Medical Boards,” Grant and Alfred, Journal of Health Politics Policy and Law, vol. 32, no. 5, October 2007. xxv Link to Public Citizen hospital actions study: http://www.citizen.org/hrg1937

https://www.veridoc.org/overview.aspx

http://www.doh.wa.gov/Portals/1/Documents/3000/MD2011-07.pdf

http://www.citizen.org/hrg1937

Washington State Medical Commission 4SHB1103 Report: Appendices

1

Washington State Medical Quality Assurance Commission

Fourth Substitute House Bill 1103 Pilot Project Report Appendices

mtm1303

Typewritten Text


2

Contents

Appendix A: Awards and Honors

Appendix B: Board-to-Board Program

Appendix C: Educational Conference/Workshop

Appendix D: Demographics Report

Appendix E: Performance Measures Defined

Appendix F: Aggregate Performance

Appendix G: Defaults, Duplicate Cases, Representation

Appendix H: History of the Medical Commission

Appendix I: Reduction in opioid-related deaths in Washington

Appendix J: Federation of State Medical Boards Letter of Support

Appendix K: Regence Health Systems Letter of Support


3

Appendix A: Commission Members and Staff Receive National Awards,

Honors, and Appointments

Individual Commission members and staff have been honored as follows:

• Past Commission Chair, Samuel Selinger, MD, won the FSMB’s John H. Clark Leadership Award in 2011 for his contributions to the Commission and the medical profession in Washington. He also gave a Technology, Entertainment, and Design (TED: Ideas Worth Spreading) talk on professionalism. (http://www.youtube.com/watch?v=rcktyGjOW-Q)

• Mimi Pattison, MD, the current Chair of the Commission, was awarded the 2010 Sojourn award from the Regence Foundation, Regence Health Plan. This award came with a $50,000 grant, which Dr. Pattison donated to support a program for people with mental illness who need palliative medicine and end-of-life care with the Franciscan Hospice and Palliative Care organization.

• Leslie Burger, MD, Immediate Past Chair is a member of the FSMB Foundation. The Foundation undertakes educational and scientific research projects designed to expand public and medical professional knowledge and awareness of challenges impacting health care and health care regulation.

• Public Member Frank Hensley was appointed to the FSMB Finance Committee.

• Staff Attorney Larry Berg was appointed to the FSMB Editorial Board for the Journal of Medical Regulation.

• Physician Assistant Member Ellen Harder was appointed by the FSMB as a representative to the National Commission on Certification of Physician Assistants (NCCPA).

• Executive Director, Maryella Jansen was invited by the FSMB to attend a tri-regulator symposium related to the Uniform Application Process and a meeting in Washington, D.C. to address the future of medical regulation.

• Staff Attorney Jim McLaughlin asked to present on the Commission’s pain rules at FSMB state medical board attorney national conference.

• Legal Unit Manager, Michael Farrell, served on an Administrators in Medicine assessment team to evaluate the North Carolina Medical Board.

http://www.youtube.com/watch?v=rcktyGjOW-Q


4

Appendix B: Board-to-Board Program

Washington State Medical Commission Board to Board Discussion: AL

2/21/12

1. Please describe the structure and composition of your board.

a. Number of members: BME: 15 MDs elected by MD leadership of AL, Licensure Comm: 7 MDs, 1 PM (2 from speaker of house, 2 from Lt. Gov, 2 from Gov, 1 from ?)

b. Number of staff: 31, all at-will employees. Larry is of the opinion that more independence leads to less turnover in staff-specifically EDs, due to not having to serve two masters.

c. Licenses regulated: MD, DO, PA, Special Purpose (telehealth), Anesthesiologist Asst.

d. Number of licensees: 738 Dos, 14,361 MDs (10k in-state), 596 PAs, 25 Spec., 21 An Asst.

e. Type of model: Functionalized, Vertical, Hybrid

f. Autonomy: Umbrella, Independent, Hybrid

2. How would you describe your level involvement with FSMB? High. Current Board Member, Three past presidents, four past BoDs, Larry was one of the first certified execs.

3. Do you use the FSMB Universal Application? No.

a. What level of integration do you have? (PDF, Excel, web service)

b. What is your satisfaction level with this system? 85% renew online, but still have paper initial apps due to FBI prints.

4. Do you use a government licensing/regulation database solution? Yes.

a. Whom do you use? Lundlan & Assoc., (ALDA)

b. What aspects of your business does the database software perform? All. Licensing, investigations, litigation, accounting, budget, CME audits.

c. How long have you had the system? Since 2006, switched from CAVU. Most recently the operation changed to one man and this has worked better for customization.

d. What is your satisfaction level with the system? High.

e. Do you host your own servers? Yes. Three in-house and then they outsource the email.

f. Do you have dedicated IT staff? Yes, 1 (Carl Martin)

5. Do you have performance measures in place in your organization? Not really. The oversight exercised by the Board works better than performance measures. a. If so, what are your targets? Same day verifications.


5

b. If not, have you considered implementing them?

6. Is your organization taking action regarding prescription of long acting opioids for chronic non-cancer pain? Board has developed guidelines and is in the process of putting forward a rule.

7. Is Telehealth an issue your organization has addressed? What was that process and solution? Yes. They have a special purpose license that allows cross state lines practice if there is a reciprocal law in other state. Still working on addressing the issue of in-state telehealth. They have specific circumstances in place for prison and mental health situations that involve a lower level medical professional to be there and guide the exam.

8. Other:

• Biggest challenges: 1. Staying independent and 2. Dealing with Pill Mills/ glorified drug dealers.

• Complaints per year: 500-750

• Investigate per year: 125-150

• Board members and staff all have laptops

• Board members all now have iPads

o Dedicated log in on the website to get and download the documents for meetings

o Use good reads to open, view and edit

o BoardBook program to create the board books

• Must have an Alabama Controlled substances certificate prior to getting DEA license o $160/year/licensee

• CME is offered to their Board members for their annual workshop


6

Washington State Medical Commission Board to Board Discussion: AZ

01/10/12

1. Please describe the structure and composition of your board. a. Number of members: 12: 8 MD, 4 PA, 1 RN

b. Number of staff: 36, down from 51 three years ago. Includes part time 6 investigators and 4 part time MD investigator/reviewers.

c. Licenses regulated: MD, PA

d. Number of licensees: 21k MD, with 16k in-state, 2,400 PA



10% of revenue goes to general fund. Referred to as 90/10 Boards.

2. How would you describe your level involvement with FSMB?

High level. AZ has two members on Board of Directors and the ED is on one workgroup.

3. Do you use the FSMB Universal Application? No, looking to implement soon.

a. What level of integration do you have? PDF, Excel, web service

b. What is your satisfaction level with this system? Use veridoc and very satisfied with the system once it went live.


a. Whom do you use: GL Solutions

b. What aspects of your business does the database software perform? All investigation, case disposition, and some administrative.

c. How long have you had the system: Three years.

d. What is your satisfaction level with the system? Described as a troubled marriage, but both parties want to work on it. Issue revolves around communication, both from GL to AZ and within GL internally.

e. Do you host your own servers? Yes.

f. Do you have dedicated IT staff? Yes. Four staff currently but may be looking to reduce.

5. Do you have performance measures in place in your organization? Yes.

a. If so, what are your targets? Investigations-Number of open investigations at or around 300, Length of investigations. Licensing-time to produce deficiency letters, time to issue approval letters CIRC-Internal investigation review committee: they prepare the case and make disciplinary recommendations to be presented to the board at the next meeting. Also


7

procures expert reviews. AZ gets experts on all investigations. They pay $150 each and provide CME credit to the MD. There is training available on the AZ website for expert reviews.


6. Is your organization taking action regarding prescription of long acting opioids for chronic noncancer pain? Adopted FSMB guidelines. Need for action on education but AZ does not know what it will look like at this point.

7. Is Telehealth an issue your organization has addressed? What was that process and solution? They are in the research and development stage. They have in-state Telehealth (rural applications) but have yet to address interstate issues.

8. Other: Legislative session started on 1/10/12. Legal: 75 actions per year, 24% involved prescribing

• PAs: Two years ago the law changed to delegation agreement, which would be kept at the clinical level. So far, AZ has not seen an issue.


8

Washington State Medical Commission Board to Board Discussion: CA

09/04/2012


a. Number of members: 15; eight MD and seven public. Members do not review cases until charges presented. Staff assesses and determines if investigation is warranted.

b. Number of staff: 271, 50 part-time, 70 percent enforcement

c. Licenses regulated: 124k MD, 6k midwives, PAs Psych, spectacle lens, Polysomnographers

d. Number of licensees:

e. Type of model: Functionalized, Vertical, Hybrid MBC controls all functions of discipline and collaborates with AGO to prosecute.

f. Autonomy: Umbrella, Independent, Hybrid Dependent on Department of Consumer Affair for admin support, but completely autonomous on policy, legislation, and budget.

2. How would you describe your level involvement with FSMB? Former members on FSMB board and Foundation. Participate but don’t mandate FCVS.



b. What is your satisfaction level with this system?


a. Whom do you use? Old multi-database system. Moving to a new off the shelf/custom system by Iron Data.

b. What aspects of your business does the database software perform? Should do everything from licensing to enforcement.

c. How long have you had the system? Should be live December 2012.

d. What is your satisfaction level with the system? Unable to answer for new system, but unsatisfied with old. No pay until live with new system.

e. Do you host your own servers? Yes, in 12 district offices.

f. Do you have dedicated IT staff? Yes, 30 dedicated for MBC, more for Dept. of Consumer Affairs.


a. If so, what are your targets? Licensure and enforcement targets. Currently take about a year to resolve a case. This is an improvement. They use an average timeframe with investigations and case disposition combined. Board members are not involved in complaints or


9

investigations. Board members perform role of judicial review.


6. Is your organization taking action regarding prescription of long acting opioids for chronic noncancer pain? Yes, on a case by case basis. Working on a prescribing summit with Board of Pharmacy in February 2012. Under prescribing is rare.

7. Is Telehealth an issue your organization has addressed? What was that process and solution? 2290.5 requires MD owned clinics, telehealth statute requires informed consent of the patient for that treatment modality.

8. Other:

• Medical Cannabis, they have recommendations but do not approve exemptions. • Expert reviewers are compensated at $150/hr. If performing exam on licensee then

usual and customary. $200/hr. for hearing. Training program for expert reviewers (over 1000) for bias, timeliness, and testimony training. Get CME for the training.

• High profile cases. Press is the issue and it snowballs into the legislature. Legislation and public information is one office for this reason.

• MOL. Manager assigned to track. 20 percent or more do not have board certification. Playing a waiting game for national movement.

• IMG legislation. If institutional pathway chosen, they would need to know that it is for Washington only. Would not be eligible for full licensure in another state.


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Washington State Medical Commission Board to Board Discussion: GA

3/20/2012


a. Number of members: 13 MD, 2 Consumer, 1 PA (ex-Officio)

b. Number of staff: 25, down from 32 due to budget

c. Licenses regulated: MD (Allo/Osteo), PA, Resp, Profu, Accu, Othot, Prescriptive Auth of ARNP

d. Number of licensees: 32k MD, 3.4k PA



2. How would you describe your level involvement with FSMB? Accept FCVS, USMLE

3. Do you use the FSMB Universal Application? No, but planning to look at it in May.




a. Whom do you use? Iron Data-Versa

b. What aspects of your business does the database software perform? Licensing, enforcement, backbone of daily ops

c. How long have you had the system? Twelve Years

d. What is your satisfaction level with the system? Like it more through upgrades.

e. Do you host your own servers? Yes. Also have a centralized tech system, similar to DES.

f. Do you have dedicated IT staff? Yes. One who does multitude of things.

5. Do you have performance measures in place in your organization? Yes. The Governor required them several years ago.

a. If so, what are your targets?

i. Decrease processing time, once application hits the door.

ii. Complaints are open and acknowledged within three days.

iii. Next five days are triage by Chief Investigator

iv. 30 day, 60 day, 90 day review of progress in cases


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v. No investigative timeline, but do a weekly status report sent to all investigators and management.

vi. They have a legal services attorney for dealing with public disclosure, but no staff attorney unit. Prosecution done at the AGO.

vii. 2,000 complaints per year with around half investigated.

b. If not, have you considered implementing them? NA.

6. Is your organization taking action regarding prescription of long acting opioids for chronic noncancer pain? Yes. Modeled their pain clinic rules after WA and FL rules. Are working to craft rules to head off legislation.

7. Is Telehealth an issue your organization has addressed? What was that process and solution? They are looking at a complete re-working of the rule with a focus on H&P existing between patient and provider. Very often getting presentations from companies about how Telehealth could work for a business model.

8. Other: Just did the OBS rule, copied from WA model directly. They are a general fund state. They can retain non-application charges.


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Washington State Medical Commission Board to Board Discussion: ID

12/6/11 1. Please describe the structure and composition of your board.

a. Number of members: 4 MD, 1 Public on advisory. BoM is 2 Public, Director of Law Enforcement, 6 MD, 1 DO

b. Number of staff: 13.8

c. Licenses regulated: MD, DO, PA, AT, DIET, RT, ATHL, POLY SOMN

d. Number of licensees: 10K, 9.2K without training licenses



2. How would you describe your level involvement with FSMB? Extensive, paid consultant through the license portability grant. Do you use the FSMB Universal Application? Yes.


b. What is your satisfaction level with this system? Not as quick as anticipated. Cannot account for the delay between staff and applicant processes.


a. Whom do you use? Custom in-state solution

b. What aspects of your business does the database software perform? Everything. Licensing, discipline, litigation, notifications in administration functions. Web service integration and website coordination.

c. How long have you had the system? 2003.

d. What is your satisfaction level with the system? Very high. Very responsive to their needs.

e. Do you host your own servers? Hosted by state IT, but has limited access.

f. Do you have dedicated IT staff? 1 for database, 1 for web services

4. Do you have performance measures in place in your organization? Yes, they are outcome based.

a. If so, what are your targets? Improve licensing process to 90% online, No paper apps but will print UA if no internet, Succession plans.

b. If not, have you considered implementing them? Not very specific PMs like MQAC has relating to processes.


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5. Pre-Litigation Hearing Panels

a. Function is to take all malpractice claims before the panel to determine if they have merit to proceed i. Composed of attorney (chair), MD member, Public member, lawyer for claimant, MD or hospital rep as expert.

ii. These are not discoverable in legal and not reportable to the Board

iii. $600 per hearing to the chair that is not reimbursed

iv. This process does not prevent litigant from going forward to the courts

b. $250k malpractice cap, non-economic damages have a different limit

c. 60-70 percent of cases brought before this panel are found to have no merit

d. Acts as a screening tool in malpractice

6. Is your organization taking action regarding prescription of long acting opioids for chronic noncancer pain? Adopted the FSMB statement on the issue. Opioids are a major problem in the state, specifically wholesaler issues. (WA could be affected by cross border runs on the east side. A PMP is in existence in ID.

7. Is telemedicine an issue your organization has addressed? What was that process and solution? Yes and it is not unique practice. Same standards apply but the process is expedited based on a non-derogatory practice history with a five-year timeframe.

8. FMG’s Established a criteria in law to determine whether a international medical school is recognized. (In existence for 15 years, with first graduate coming 15 years ago). They have three-year progressive training requirement, recognize CAN, and have authority to recognize others on an individual basis. Have recognized U.K. and AUS so far.


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Washington State Medical Commission Board to Board Discussion: KS

7/19/11


a. Number of members: n/a

b. Number of staff: n/a

c. Licenses regulated: RN and social sciences

d. Number of licensees: 17k including out of state



2. How would you describe your level involvement with FSMB? N/A Do you use the FSMB Universal Application? Yes


b. What is your satisfaction level with this system? Needs work to be efficient.


a. Whom do you use? GL Solutions

b. What aspects of your business does the database software perform? Credentialing and discipline

c. How long have you had the system? 2007

d. What is your satisfaction level with the system? Very dissatisfied


f. Do you have dedicated IT staff? Yes.

4. Do you have performance measures in place in your organization? No.

a. If so, what are your targets?


5. Is your organization taking action regarding prescription of long acting opioids for chronic noncancer pain? N/A

6. Is telemedicine an issue your organization has addressed? What was that process and solution? N/A

7. Other: • Receive 2,400 complaints per year • Receive malpractice when it is filed, not settled. 7% of those turn into investigations.


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Washington State Medical Commission Board to Board Discussion: NC


a. Number of members: 12; 8MD, 1PA, 3 Public

b. Number of staff: 55

c. Licenses regulated: MD, PA, DO, Anest. Assist, Perfusionist, ARNPs (jointly), Clinical Pharm (jointly),

d. Number of licensees: 32, 644 MD, DO. 4,458 PA, 2,455 Residency



2. How would you describe your level involvement with FSMB? Very involved. Dr. Rhyne is FSMB chair and is past member of NCBOM, most staff are certified medical XXX (Executive, investigator, attorney)

3. Do you use the FSMB Universal Application? No. In-house online apps exist.



4. Do you use a government licensing/regulation database solution?

a. Whom do you use: GL Solutions

b. What aspects of your business does the database software perform? Licensing, enforcement, online applications, renewals, administration

c. How long have you had the system: Since 2004

d. What is your satisfaction level with the system? It gets better over time. Started with CAVU and those that complain do not remember the difficulties of CAVU. A large issue is that the eLicensing market is small and limited so there is not the clear guidelines and development available to refine the offerings.

e. Do you host your own servers? GL hosts servers

f. Do you have dedicated IT staff? One for non GL servers, Operations Director and a .5 FTE for software.

5. Do you have performance measures in place in your organization? They are informal and non-specific.

a. If so, what are your targets? If an investigation has not been completed in 6 months, then a status report must be sent to complainant. All cases over one year must be reported to the Board.


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6. Is your organization taking action regarding prescription of long acting opioids for chronic noncancer pain? They have a physician statement from FSMB that has been in place. NC is familiar with the WA rules but the Board does not seem to have a desire to go that route. NC does require use of PMP if under compliance, but it is based on the honor system. PMP has been in place or five years. It is clunky, has a mandatory attestation about being for professional use only, which creates issues for offices doing multiple doc entry. Also issues with large offices just putting one doc as prescriber to save data entry time.

7. Is Telehealth an issue your organization has addressed? What was that process and solution? Very active and ongoing issue. Primary problem is getting approached by vendors for approval of new business models.

8. Other: NC expert review system is 300 individuals who volunteer or check box on renewal to volunteer. Charge is $150 per hour and each case is two-four hours for each case. NC is spending about $10k/month on external review.


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Washington State Medical Commission Board to Board Discussion: OH


a. Number of members: 12-9 MD, 1 DO, 1 PD, 3 Public

b. Number of staff: 87 but down to 79 due to budget

c. Licenses regulated: MD, DO, PD, Anest. Assist, RA

d. Number of licensees: 65k, 42k MD



2. How would you describe your level involvement with FSMB? High. First with FCVS adoption, many offices held on BoD, many trained in SMB training prog.



b. What is your satisfaction level with this system? Would like it to be improved.

4. Do you use a government licensing/regulation database solution?

a. Whom do you use: Cavu

b. What aspects of your business does the database software perform? Licensing. Was using enforcement module but had to drop it and revert to paper.

c. How long have you had the system: 2004

d. What is your satisfaction level with the system? Extreme dissatisfaction.

e. Do you host your own servers? No.

f. Do you have dedicated IT staff? Centralized agency.

5. Do you have performance measures in place in your organization?

a. If so, what are your targets? Yes. Email will follow detailing. We consider performance measures to be light flashing on the dashboard.


6. Is your organization taking action regarding prescription of long acting opioids for chronic noncancer pain? Ohio addressed the issue of pill mills and prescription practices. The overall understanding is that we need to get a better understanding of appropriate pain management. Regarding communication strategies; brought in outside entities, newsletter, website, associations of Ohio. Gave 105 presentations on it since Jan (?), and have a dedicated Education


18

consultant.

7. Is Telehealth an issue your organization has addressed? What was that process and solution? This issue has always been percolating but in the last three months it has raised up to be a major issue. Largely due to a company called Health Spot. What needs to be nailed down is what is essential for an exam, which leads to more technical questions.

8. Other: Legislators meet year round. Expert witness: they go to the medical association and sell it like medical jury duty. Use of nurses: Ohio has a Quality Intervention Panel (QIP) that looks to standard of care violations, all are referred to this panel with education being the goal. This seems similar to the NCQAC Early Remediation program. Nurses also act as reviewers for investigative files. All investigators are law enforcement background.


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Washington State Medical Commission Board to Board Discussion: OR


a. Number of members: 12

b. Number of staff: 40

c. Licenses regulated: MD, DO, PA, Podi, Accu

d. Number of licensees: 17k including out of state


f. Autonomy: Umbrella, Independent (under exec with Legislative budget control), Hybrid

2. How would you describe your level involvement with FSMB? On AIM and re-entry panel, IAMRA

3. Do you use the FSMB Universal Application? No. They have their own.




a. Whom do you use? GL Solutions. Spent $500k on start up. Very automated.

b. What aspects of your business does the database software perform? All

c. How long have you had the system? 2010

d. What is your satisfaction level with the system? Good. Likes it.


f. Do you have dedicated IT staff? 3: 1 trouble shoots and 1 business apps. Remainder is a double fill.


a. If so, what are your targets? License processes (Internal), Days to renew, cases upheld on appeal, customer service, board best practices (informing board members), Recidivism (5% have a complaint within five years), Law says case goes to board in 120 days with possible 30-day extension granted by the ED.


6. Is your organization taking action regarding prescription of long acting opioids for chronic noncancer pain?

7. Is telemedicine an issue your organization has addressed? What was that process and solution?


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Telemedicine license, consultation is not considered telemedicine. Zoom care has started a Skype service that is in limited test in Portland.

8. Other: Medical Director sends systems letters when requested to address issues that BOM cannot take definitive action on.


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Appendix C: Educational Conference/Workshop

Every year the Medical Commission meets for two days to educate the Commission members, staff, and interested parties on topics of relevance to the Commission and medical regulation. This workshop model has served the Commission well as a forum to work on difficult policy issues or hear from nationally known speakers. At the workshop in 2011, aviation expert John Nance, author of Why Hospitals Should Fly, spoke about how aviation safety principles can be applied to improve patient safety in hospitals. In 2012, the Commission successfully transitioned from the workshop model to the educational conference model. Attendees came from across Washington, and the presenters were nationally and internationally known experts in their fields. Topics included patient safety, the latest opioid research, social media and professionalism. The Commission plans to expand the offerings for the conference in coming years as a public service to all licensees, the public and other interested parties.

The Medical Commission assembles informational packets for the annual workshops to be downloaded by the attendees.

• 2012:http://www.doh.wa.gov/Portals/1/Documents/3000/MQACWorkshopPacket2012.pdf • 2011:http://www.doh.wa.gov/Portals/1/Documents/3000/Washington%20State%20Medical%20

Quality%20Assurance%20Commission%20Workshop%20Reading%20Materials.pdf

Complete biographies for the 2012 workshop presenters can be found on the Medical Commission website.

• http://www.doh.wa.gov/Portals/1/Documents/3000/Medical%20Commission%202012%20Workshop%20Speaker%20Biographies.pdf

http://www.doh.wa.gov/Portals/1/Documents/3000/MQACWorkshopPacket2012.pdf

http://www.doh.wa.gov/Portals/1/Documents/3000/Washington%20State%20Medical%20Quality%20Assurance%20Commission%20Workshop%20Reading%20Materials.pdf

http://www.doh.wa.gov/Portals/1/Documents/3000/Washington%20State%20Medical%20Quality%20Assurance%20Commission%20Workshop%20Reading%20Materials.pdf

http://www.doh.wa.gov/Portals/1/Documents/3000/Medical%20Commission%202012%20Workshop%20Speaker%20Biographies.pdf

http://www.doh.wa.gov/Portals/1/Documents/3000/Medical%20Commission%202012%20Workshop%20Speaker%20Biographies.pdf


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Washington State Medical Commission Educational Workshop 2012

Into the Future: Designing Better Patient Safety Systems

WEDNESDAY – August 22, 2012 – Capital Event Center

Breakfast Provided in Main Rooms

8:15 a.m. Welcome: Mimi Pattison, MD, Chair and Secretary of Health Mary Selecky

8:30 a.m.

Dennis Turk, PhD John & Emma Bonica Professor of Anesthesiology & Pain Research University of Washington Evidence Based Practice

9:30 a.m. Break

9:45 a.m. Jon Thomas, MD, MBA President, MN Board of Medical Practice, Chair-elect FSMB Social Media and Medical Practice

10:45 a.m. Jane Ballantyne, MD Professor of Education and Research University of Washington Managing Bill 2876

12:00 p.m. Lunch Provided

Presentation: RADM Patrick O’Carroll, MD Assistant Surgeon General, USPHS, Region X The Affordable Care Act Introduction: Karen Jensen, JD, MS Assistant Secretary, Department of Health

1:30 p.m. Networking Break

2:00 p.m.

Breakout 1 1. Commission efforts: Chehalis A

Pain Rule, Demographics, Pilot to Date 2. Jon Thomas, MD, MBA: Chehalis B

President, MN Board of Medical Practice, Chair-elect FSMB Telehealth innovations in Minnesota

3:00 p.m.

Breakout 2 1. Commission efforts: Chehalis A

Pain Rule, Demographics, Pilot to Date 2. Jon Thomas, MD, MBA: Chehalis B

President, MN Board of Medical Practice, Chair-elect FSMB Telehealth innovations in Minnesota

4:00 p.m. Break

4:15 p.m. Wrap up and discussion from breakouts, general day wrap


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THURSDAY – August 23, 2012 – Capital Event Center

Breakfast Provided in Main Rooms

8:15 a.m. Welcome: Mimi Pattison, MD, Chair

8:30 a.m. Gary Kaplan, MD Chairman and CEO, Virginia Mason Health System Seeking Zero Defects: Creating a Patient Safety Culture

9:30 a.m. Break

9:45 a.m. Lisa Robin, MLA Chief Advocacy Officer with Federation of State Medical Boards Challenges to State Based Licensure

10:45 a.m. Barbara Schneidman, MD, MPH Clinical Professor of Psychiatry and Behavioral Sciences University of Washington Sexual Boundary Violations and Board Diversity

12:00 p.m. Lunch Provided

Presentation: Margaret O’Kane, MHA President, National Committee for Quality Assurance Protecting Patients within and without Systems

1:30 p.m. Networking Break

2:00 p.m. Interactive Demonstration: Time Out

2:45 p.m.

Breakout 1 1. Stuart Freed, MD: Chehalis A

Chief Medical Officer, Wenatchee Valley Medical Center Systematic Approach to patients with Chronic Non-Malignant Pain

2. Lisa Robin, MLA: Chehalis B Legislative trends: State level and Federal

3:30 p.m.

Breakout 2 1. Stuart Freed, MD: Chehalis A

Chief Medical Officer, Wenatchee Valley Medical Center Systematic Approach to patients with Chronic Non-Malignant Pain

2. Lisa Robin, MLA: Chehalis B Legislative trends: State level and Federal

4:15 p.m. Break

4:25 p.m. Closing: Workshop Debriefing and Wrap-up

FRIDAY – August 24, 2012- PPE, Rooms 152 and 153 – Closed Sessions

8:00 a.m.-12:00 p.m. Case Reviews


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2012 Workshop Speakers

Jane C. Ballantyne, MD

Professor of Education and Research

University of Washington Medicine Dr. Jane Ballantyne is the University of Washington Medicine Professor of Education and Research in the Department of Anesthesiology and Pain Medicine. Born in Bristol, United Kingdom, Dr. Ballantyne graduated with her medical degree from the Royal Free Hospital School of Medicine in London. She is a member of the Royal College of Surgeons for Otolaryngology and Anaesthesia. She is also a member of the Royal College of Anaesthetists. In 1997, she became a Diplomate of the American Board of Anesthesiology.

Stuart D. Freed, M.D.

Medical Director

Wenatchee Valley Medical Center Stuart D. Freed, MD is the current Medical Director of Wenatchee Valley Medical Center. Dr. Freed attended Pacific Lutheran University for his undergraduate studies and received his medical degree from University of Washington in 1984. Dr. Freed completed his residency in 1987 at the University of Washington/Tacoma Family Medical Center and received his Board Certification from the American Board of Family Practice the same year. Dr. Freed specializes in Sports Medicine.

Karen A. Jensen, JD, MS

Assistant Secretary to the Department of Health

Health Systems Quality Assurance Karen Jensen was appointed as an Assistant Secretary to the Department of Health in August 2008. She leads the Health Systems Quality Assurance Division. This is the department’s largest division, with nearly 400 employees. Among other responsibilities, the division licenses more than 300,000 health professionals in Washington State. Karen began working with the department in May 2000 when she was still with the Attorney General's Office. Karen formally joined the department in 2004 and assumed responsibilities as one of the supervising staff attorneys in the division’s Legal Service Unit. She worked most recently as the division’s policy director and legislative coordinator. Karen has a Bachelor’s degree and Master’s degree in microbiology from Washington State University, as well as a Juris doctor from Seattle University.


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Gary S. Kaplan, MD

Chairman and CEO

Virginia Mason Health System Gary S. Kaplan, MD, FACP, FACMPE, FACPE, has served as chairman and CEO of the Virginia Mason Health System since 2000. He is a practicing Internal Medicine physician at Virginia Mason.

During Dr. Kaplan's tenure as chairman and CEO, Virginia Mason has received significant national and international recognition for its efforts to transform health care.

Dr. Kaplan received his medical degree from the University of Michigan and is board certified in internal medicine. He is a Fellow of the American College of Physicians (FACP), the American College of Medical Practice Executives (FACMPE) and the American College of Physician Executives (FACPE).

RADM Patrick O'Carroll, MD, MPH

Assistant Surgeon General, U.S. Public Health Service Regional Health Administrator, Region X, Seattle

States: Alaska, Idaho, Oregon, and Washington

RADM Patrick O’Carroll, a career Commissioned Officer in the U. S. Public Health Service (USPHS), has served as Regional Health Administrator for Region X since January 2003. As RHA, Dr. O’Carroll serves as the Region’s senior physician and scientist representing the Assistant Secretary for Health, the Secretary, and the U.S. Department of Health and Human Services.

Margaret E. O'Kane, MHA

President

National Committee for Quality Assurance Since 1990, Margaret E. O’Kane has served as President of the National Committee for Quality Assurance (NCQA), an independent, non-profit organization whose mission is to improve the quality of health care everywhere. Under her leadership, NCQA has developed broad support among the consumer, employer and health plan communities. About three-quarters of the nation’s largest employers evaluate plans that serve their employees using Healthcare Effectiveness Data and Information Set (HEDIS®) data. In recent years, NCQA has received awards from the National Coalition for Cancer Survivorship, the American Diabetes Association and the American Pharmacists’ Association. Ms. O’Kane began her career in health care as a respiratory therapist and went on to earn a master’s degree in health administration and planning from the Johns Hopkins University.


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Lisa A. Robin, MLA

Chief Advocacy Officer

Federation of State Medical Boards For more than 17 years, Lisa Robin has been active in leading the Federation of State Medical Boards in developing and promulgating policy on a broad range of issues supporting state medical boards in their mission of public protection. Under her oversight, the FSMB has addressed the issues of physician impairment, telemedicine, pain management, scope of practice, professional conduct and ethics, Internet prescribing, the regulation of office-based surgery, and complementary and alternative medicine. Lisa established and currently leads the FSMB’s Washington D.C. advocacy office.

Barbara S. Schneidman, MD, MPH

Clinical Professor of Psychiatry and Behavioral Sciences

University of Washington School of Medicine Barbara S. Schneidman, MD, MPH was the Vice President of Medical Education at the American Medical Association from 2002-2008. Prior to this position she served as the Associate Vice President of the American Board of Medical Specialties (ABMS), from 1993-1998. During 2009 she served as the Interim CEO and President of the Federation of State Medical Boards.

Mary C. Selecky

Secretary of Health

Washington State Mary C. Selecky has been Secretary of the Washington State Department of Health since March 1999, serving under Governor Chris Gregoire and former Governor Gary Locke. Prior to working for the state, Mary served for 20 years as administrator of the Northeast Tri-County Health District in Colville, Washington.


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Jon V. Thomas, MD, MBA

President, Minnesota Board of Medical Practice

Chair-elect, Federation of State Medical Boards After completing residency at Mayo Graduate School of Medicine in Otolaryngology-Head and Neck Surgery in 1993, Dr. Thomas joined a group of 3 Otolaryngologists in St. Paul, MN. Over the ensuing decade, the group of 3 has grown to a group of 21 through acquisition and merger. Since 2006, Dr. Thomas has served as President and CEO of the combined entity, Ear, Nose & Throat SpecialtyCare of Minnesota. In 2001 Dr. Thomas earned an MBA in Medical Group Management from the University of St. Thomas in St. Paul, MN.

Dennis C. Turk, PhD

John and Emma Bonica Professor of Anesthesiology and Pain Research

University of Washington Dennis C. Turk, PhD, is the John and Emma Bonica Professor of Anesthesiology and Pain Research, Director of the Center for Pain Research on Impact, Measurement, & Effectiveness (C-PRIME) at the University of Washington, and a Special Government Employee within the US Food and Drug Administration. He is currently Editor-in-Chief of The Clinical Journal of Pain, Co-director of the Initiative on the Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT), and Associate Director of the Analgesic, Anesthetic, and Abuse Clinical Trials Translations, Innovations, Opportunities, & Networks (ACTTION) and FDA-sponsored public-private partnership. His research has been funded continuously by NIH since 1977 and has been funded by the National Center for Health Statistics, the National Center for Medical Rehabilitation Research, as well as by a number of private companies and foundations. Dr. Turk has published over 500 journal articles and chapters in scholarly texts, and has written and edited 20 volumes, most recently, The Pain Survival Guide: How to Reclaim Your Life and Chronic Pain: An Integrated Biobehavioral Approach.


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Appendix D: Demographics Report

Demographic Census Report Allopathic Physicians and Physician Assistants

The Medical Quality Assurance Commission recognizes the value having accurate information on physicians and physician assistants licensed in Washington. In 2011, the Washington State legislature passed SB 5480 allowing the Medical Commission to collect demographic data for physicians and physician assistants.

The Medical Commission created an individualized demographic census for physicians and physician assistants. Each census includes questions on practice settings, medical specialty, and certifications. The Commission will share the demographic data with our state and federal partners as part of workforce planning efforts and minimum-data-set reporting requirements.

The Medical Commission began collecting data in March 2012 for physicians and in July 2012 for physician assistants. Currently, physicians and physician assistants receive the demographic census with their license renewal reminder. An on-line version of the census will be available in January 2013.

The Medical Commission also developed a Demographic Census Report for physicians and for physician assistants. These reports compile answers to the census questions and display the data using a variety of formats. The Physician Demographic Census Report for March 1, 2012 through November 30, 2012 is included for reference.

In Washington, physician and physician licenses are valid for 2 years. The Medical Commission will complete the first full cycle of data collection in March of 2014 for licensed physicians and July 2014 for licensed physician assistants.


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Physicians Demographic Census Report I – Physician Information______________________________ Census start date: 3/1/2012 Created on: 12/3/2012 Census end date: 11/30/2012 Total returns: 4,307 ______________________________________________________________________ Gender Status Male 2,987 69.4% Retired 145 3.4% Female 1,320 30.6% Retired Active 48 1.1% ______________________________________________________________________ Date of Birth Total Percentage Male Male % Female Female % 1900-1945 600 13.93% 543 90.50% 57 9.50% 1946-1964 2,408 55.91% 1,735 72.05% 672 27.91% 1965-1982 1,296 30.09% 707 54.55% 589 45.45% 1983-2001 3 0.07% 1 33.33% 2 66.67% ______________________________________________________________________ Number of Census Forms Returned by Month and the Average:

6. In what US state or foreign country did you obtain your physicians degree?

Washington State: 686 15.93% Other US State: 2,833 65.78% US Territories*: 5 0.12% Unknown US: 147 3.41% Foreign Country: 591 13.72% Unknown: 45 1.04%


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7a. Do you currently reside in Washington State? Yes 3,283 76.2% No 1,024 23.8%

______________________________________________________________________ 7c. Home State if not Washington:

Alabama 12 Illinois 10 Montana 11 Rhode Island 0 Alaska 11 Indiana 6 Nebraska 5 South Carolina 2 Arizona 34 Iowa 6 Nevada 11 South Dakota 1 Arkansas 1 Kansas 4 New Hampshire 0 Tennessee 11 California 155 Kentucky 6 New Jersey 6 Texas 50 Colorado 13 Louisiana 2 New Mexico 5 Utah 8 Connecticut 2 Maine 1 New York 15 Vermont 1 Delaware 0 Maryland 8 North Carolina 11 Virginia 11 District of Col. 4 Massachusetts 7 North Dakota 5 West Virginia 1 Florida 32 Michigan 8 Ohio 13 Wisconsin 16 Georgia 7 Minnesota 9 Oklahoma 7 Wyoming 2 Hawaii 15 Mississippi 2 Oregon 274 British Columbia 8 Idaho 46 Missouri 9 Pennsylvania 11 Other foreign 39

______________________________________________________________________ 8a. Do you currently practice in Washington State? Yes 3,283 76.2% No 1,024 23.8%

*US Territories include: Puerto Rico, Guam, American Samoa, Virgin Islands (US), and minor outlying islands


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9a. Primary Site Zip (Note: some zip codes cross county lines)

Northwest Washington

Central Washington

Island 20 Benton 74 King 1,359 Chelan 47 Pierce 312 Douglas 1 San Juan 5 Grant 9 Skagit 60 Kittitas 5 Snohomish 209 Klickitat 3 Whatcom 92 Okanogan 17

Total 2,057 Yakima 74

Total 230

Southwest Washington

Eastern Washington Clallam 35 Adams 3 Clark 192 Asotin 9 Cowlitz 37 Columbia 1 Grays Harbor 15 Ferry 1 Jefferson 10 Franklin 17 Kitsap 88 Garfield 0 Lewis 20 Lincoln 3 Mason 13 Pend Oreille 1 Pacific 4 Spokane 261 Skamania 0 Stevens 8 Thurston 121 Walla Walla 37 Wahkiakum 0 Whitman 14


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Total 535 Total 355

Oregon Border Counties Idaho Border Counties Clackamas 29 Benewah 0 Clatsop 2 Bonner 3 Columbia 1 Boundary 0 Gilliam 0 Kootenai 14 Hood River 4 Latah 4 Morrow 0 Nez Perce 10

Multnomah 81 Total 31 Sherman 0 Umatilla 3 Wallowa 0 Washington State: 3,177 Wasco 1 Non Washington State: 774 Washington 32 Unknown Location: 356

Total 92 Total: 4,307 Map Source: Census.wa.gov. Color was added, text was altered. Zip Code source: altiusdirectory.com ______________________________________________________________________ 10a1. Have you completed a residency accredited by ACGME?

Yes 3,951 91.7% No 356 8.3%

______________________________________________________________________ 10a2. Residency Specialty Allergy and Immunology 2

Orthopaedic Surgery 147

Anesthesiology 283

Otolaryngology 37 Colon and Rectal Surgery 0

Pathology - Anatomic/Clinical 115

Dermatology 51

Pediatrics 364 Emergency Medicine 136

Physical Medicine and Rehab. 64

Family Medicine 637

Plastic Surgery 26 Internal Medicine 864

Preventative Medicine 31

Medical Genetics 2

Psychiatry 232 Neurological Surgery 24

Radiation Oncology 30

Neurology 71

Radiology-Diagnostic 281 None Listed 391

Surgery 188

Nuclear Medicine 2

Thoracic Surgery 10 Obstetrics and Gynecology 163

Urology 52

Ophthalmology 104

Total: 4,307


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10b1. Board Certified by ABMS?

Yes 3,887 90.2% No 420 9.8%

______________________________________________________________________ 10b2. ABMS Specialty

Aerospace Medicine 3 Obstetrics and Gynecology 161 Allergy and Immunology 6 Occupational Medicine 9 Anesthesiology 272 Ophthalmology 102 Clinical Biochemical Genetics 0 Orthopaedic Surgery 149 Clinical Cytogenetics 1 Otolaryngology 36 Clinical Genetics 3 Pathology - Anatomic/Clinical 99 Clinical Molecular Genetics 0 Pathology - Anatomic 5 Colon and Rectal Surgery 0 Pathology - Clinical 5 Dermatology 54 Pediatrics 350 Diagnostic Radiology 294 Physical Medicine and Rehab. 59 Emergency Medicine 172 Plastic Surgery 31 Family Medicine 625 Psychiatry 198 Internal Medicine 865 Public Health and Gen. Prev. Med. 25 Medical Physics 0 Radiation Oncology 28 Neurological Surgery 29 Surgery 153 Neurology 61 Thoracic and Cardiac Surgery 17 Neurology-Qualif. in Child Neur. 1 Urology 53 None Listed 434 Vascular Surgery 6 Nuclear Medicine 1 Total: 4,307 ______________________________________________________________________ 10b4. Other Certification:

Yes 73 1.7% No 4,234 98.3%


34

11a. What is your current area of practice? Aerospace Medicine 2 Occupational Medicine 22 Allergy and Immunology 12 Ophthalmology 109 Anesthesiology 274 Orthopaedic Surgery 151 Clinical Biochemical Genetics 0 Other (e.g. Hospitalist) 151 Clinical Cytogenetics 1 Otolaryngology 37 Clinical Genetics 2 Pathology - Anatomic 7 Clinical Molecular Genetics 1 Pathology - Clinical 5 Colon and Rectal Surgery 3 Pathology - Anatomic/Clinical 96 Dermatology 58 Pediatrics 349 Diagnostic Radiology 288 Physical Medicine and Rehab. 65 Emergency Medicine 193 Plastic Surgery 33 Family Medicine 677 Psychiatry 236 Internal Medicine 796 Public Health and Gen. Prev. Med. 28 Medical Physics 0 Radiation Oncology 31 Neurological Surgery 26 Surgery (General) 146 Neurology 68 Thoracic and Cardiac Surgery 24 Neurology-Qualif. in Child Neur. 1 Urology 56 None/Unknown/Retired 187 Vascular Surgery 11 Nuclear Medicine 1 Total: 4,307 Obstetrics and Gynecology 160

*Other Surgical Specialties includes: Colon and Rectal Surgery, Neurosurgery, Ophthalmology, Otolaryngology, Urology, Plastic Surgery, Thoracic and Cardiac Surgery, and Vascular Surgery.


35

II – Practice Information ___ ___________________________ 12a. For patient related activities, indicate your applicable practice arrangement/size of group

Practice Arrangement Group size Percentage Solo Practitioner: 568 13.2% Single Specialty Group: 1,115 25.9% Multi-Specialty Group: 815 18.9% Employee of Hospital or Clinic: 866 20.1% State or Federal Employer: 385 8.9% Other: 558 13.0% Total: 4,307 100.0%

12b. Single Specialty Size of Group

Size of group Number Percentage 1-10 500 55.6% 11-25 203 22.6% 26-50 117 13.0% 51-100 62 6.9% 100+ 18 2.0%

12c. Multi-Specialty Size of Group

Size of group Number Percentage 1-100 220 41.8% 101-500 224 42.6% 501-1,000 64 12.2% 1,000+ 18 3.4%

13a-13c. Is your clinical practice primarily:

Clinical Practice Number Percentage Office based: 1,814 42.1% Hospital based: 1,074 24.9% Both: 960 22.3% Neither: 343 8.0% Unknown 116 2.7%


36

14a. Do you practice Telehealth/Telemedicine?

Answer Number Percentage Yes 407 9.4% No 3,900 90.6%

14c. Hours per week in this setting:

Hours Number Percentage <30* 242 82.3% 31-40 29 9.9% 40+ 23 7.8%

______________________________________________________________________ 15a. Do you have hospital clinical privileges?

Answer Number Percentage Yes 3,212 74.6% No 1,095 25.4%

15b. Hospital privileges outside HAC system?

Yes: 1,065 16a-16f. In a typical work week, indicate the number of hours dedicated to:

Hours <10* 11-20 21-35 36-45 46-60 60+ Avg Hrs* Clinical: 307 397 804 1,141 934 225 38.5 Research: 481 93 72 46 29 4 13.5 Administrative: 1,839 206 91 64 29 1 8.3 Education: 1,366 112 28 13 7 1 6.1 Volunteering: 484 19 4 2 2 4 5.4 Other: 140 33 18 15 4 4 14.3 Total weekly hrs: 120 135 333 810 923 489 47.1 *Does not include zero hours ______________________________________________________________________


37

17. Approximately how many weeks did you work as a physician during the last 12 months?

Weeks Number Percentage <30* 395 9.2% 31-39 140 3.3% 40-47 1,216 28.2% 48-52 2,267 52.6% Unk or zero 289 6.7%

______________________________________________________________________ 18. Do you perform office based surgery requiring more than minimal local anesthesia in your practice?


______________________________________________________________________ 19a. Do you prescribe opioids for patients with chronic non-cancer pain?

Answer Number Percentage Yes 1,385 32.2% No 2,922 67.8%

19b. If Yes, # of Patients?

Patients Number Percentage 1-10 488 44.4% 11-20 226 20.6% 21-50 217 19.7% 51-100 93 8.5% 101-250 47 4.3% 250+ 28 2.5%

*Does not include "0" 20a. Do you practice nontraditional medicine?



38

21a-21e. What languages besides English are spoken at your practice?

Language indicated on the census

Total number of forms

Percentage of all languages

Percentage of total forms

Spanish 1,144 41.92% 27% Russian 362 13.26% 8% Korean 198 7.26% 5% French 196 7.18% 5% Mandarin Chinese 314 11.51% 7% Other Language(s) 515 18.87% 12% Do Not Know 209 n/a 5%

Number of forms where any language was entered:* Number of forms: 1,392 Percentage: 32.32% *Does not include "Do Not Know"


39

Physician Primary Area of Practice by County - Northwest Washington

Island

King

Pierce

San Juan

Skagit

Snohomish

Whatcom

Total

Aerospace Medicine 0 Allergy and Immunology 7 2 9 Anesthesiology 1 78 22 1 3 13 5 123 Clinical Biochemical Genetics 0 Clinical Cytogenetics 1 1 Clinical Genetics 2 2 Clinical Molecular Genetics 0 Colon and Rectal Surgery 2 1 3 Dermatology 27 1 4 2 34 Diagnostic Radiology 1 57 19 3 18 1 99 Emergency Medicine 1 36 21 6 13 1 78 Family Medicine 4 187 49 4 15 49 29 337 Internal Medicine 2 294 48 11 32 20 407 Medical Physics 0 Neurological Surgery 10 1 2 13 Neurology 24 5 5 3 37 Neurology-Qualif. in Child Neur. 1 1 Nuclear Medicine 1 1 Obstetrics and Gynecology 1 58 9 2 2 7 79 Occupational Medicine 6 1 1 8 Ophthalmology 26 5 2 9 2 44 Orthopaedic Surgery 1 49 19 3 10 3 85 Otolaryngology 16 2 1 2 21 Pathology - Anatomic 4 1 5 Pathology - Clinical 3 3 Pathology - Anatomic/Clinical 32 6 3 2 43 Pediatrics 3 147 35 2 10 5 202 Physical Medicine and Rehab. 28 4 2 1 35 Plastic Surgery 1 13 3 3 20 Psychiatry 103 21 2 7 4 137 Public Health/Gen. Prev. Med. 9 4 1 14 Radiation Oncology 8 3 1 1 1 14 Surgery 47 11 1 5 1 65 Thoracic and Cardiac Surgery 1 8 1 2 12 Urology 16 5 3 3 27 Vascular Surgery 5 1 6 Other (e.g. Hospitalist, Admin) 3 40 15 4 9 71 None Listed or Unknown 1 14 3 3 21 Total: 20 1359 312 5 60 209 92 2057


40

Physician Primary Area of Practice by County - Southwest Washington

Clallam

Clark

Cow

litz

Grays H

arbor

Jefferson

Kitsap

Lew

is

Mason

Pacific

Skamania

Thurston

Wahkiakum

Total

Aerospace Medicine 1 1 Allergy and Immunology 0 Anesthesiology 2 12 2 1 9 1 6 33 Clinical Biochemical Genetics 0 Clinical Cytogenetics 0 Clinical Genetics 0 Clinical Molecular Genetics 0 Colon and Rectal Surgery 0 Dermatology 2 2 1 5 Diagnostic Radiology 13 2 6 2 1 8 32 Emergency Medicine 1 8 1 6 3 4 2 5 30 Family Medicine 11 32 7 5 2 18 4 6 1 29 115 Internal Medicine 5 49 11 3 2 21 1 27 119 Medical Physics 0 Neurological Surgery 2 2 Neurology 2 2 4 Neurology-Qualif. in Child Neur. 0 Nuclear Medicine 0 Obstetrics and Gynecology 15 2 1 6 24 Occupational Medicine 1 1 Ophthalmology 2 8 1 2 3 1 17 Orthopaedic Surgery 4 1 1 1 4 4 15 Otolaryngology 1 1 1 3 Pathology - Anatomic 0 Pathology - Clinical 0 Pathology - Anatomic/Clinical 1 6 3 2 1 13 Pediatrics 2 19 2 7 3 1 5 39 Physical Medicine and Rehab. 1 1 2 1 5 Plastic Surgery 1 1 2 Psychiatry 1 6 2 2 5 6 22 Public Health/Gen. Prev. Med. 1 1 2 Radiation Oncology 1 1 1 3 Surgery 1 5 2 3 1 1 5 18 Thoracic and Cardiac Surgery 0 Urology 1 2 1 2 6 Vascular Surgery 1 1 2 Other (e.g. Hospitalist, Admin) 1 7 2 2 1 3 16 None Listed or Unknown 1 2 3 6 Total: 35 192 37 15 10 88 20 13 4 0 121 0 535


41

Physician Primary Area of Practice by County - Central Washington

Benton

Chelan

Douglas

Grant

Kittitas

Klickitat

Okanogan

Yakim

a

Total

Aerospace Medicine 0 Allergy and Immunology 1 1 2 Anesthesiology 9 2 5 16 Clinical Biochemical Genetics 0 Clinical Cytogenetics 0 Clinical Genetics 0 Clinical Molecular Genetics 0 Colon and Rectal Surgery 0 Dermatology 0 Diagnostic Radiology 4 1 1 6 Emergency Medicine 3 3 1 1 1 9 Family Medicine 15 6 1 2 2 1 10 17 54 Internal Medicine 17 14 2 1 1 1 19 55 Medical Physics 0 Neurological Surgery 0 Neurology 1 1 2 Neurology-Qualif. in Child Neur. 0 Nuclear Medicine 0 Obstetrics and Gynecology 1 2 2 6 11 Occupational Medicine 3 1 2 6 Ophthalmology 4 2 2 8 Orthopaedic Surgery 3 1 3 7 Otolaryngology 0 Pathology - Anatomic 1 1 Pathology - Clinical 0 Pathology - Anatomic/Clinical 1 1 2 Pediatrics 4 3 1 1 1 8 18 Physical Medicine and Rehab. 1 1 1 3 Plastic Surgery 1 1 Psychiatry 1 1 2 4 Public Health/Gen. Prev. Med. 0 Radiation Oncology 1 1 Surgery 3 3 1 1 1 9 Thoracic and Cardiac Surgery 0 Urology 1 1 1 3 Vascular Surgery 0 Other (e.g. Hospitalist, Admin) 3 1 1 5 10 None Listed or Unknown 1 1 2 Total: 74 47 1 9 5 3 17 74 230


42

Physician Primary Area of Practice by County - Eastern Washington

Adam

s

Asotin

Colum

bia

Ferry

Franklin

Garfield

Lincoln

Pend Oreille

Spokane

Stevens

Walla W

alla

Whitm

an

Total

Aerospace Medicine 0 Allergy and Immunology 0 Anesthesiology 1 16 2 19 Clinical Biochemical Genetics 0 Clinical Cytogenetics 0 Clinical Genetics 0 Clinical Molecular Genetics 0 Colon and Rectal Surgery 0 Dermatology 6 1 7 Diagnostic Radiology 1 22 2 25 Emergency Medicine 1 4 10 2 2 19 Family Medicine 2 1 1 4 3 1 44 5 9 6 76 Internal Medicine 3 2 48 2 6 2 63 Medical Physics 0 Neurological Surgery 2 2 Neurology 4 2 6 Neurology-Qualif. in Child Neur. 0 Nuclear Medicine 0 Obstetrics and Gynecology 1 2 13 2 1 19 Occupational Medicine 1 1 2 Ophthalmology 9 9 Orthopaedic Surgery 1 11 3 15 Otolaryngology 3 3 Pathology - Anatomic 0 Pathology - Clinical 0 Pathology - Anatomic/Clinical 1 4 5 Pediatrics 19 1 1 2 23 Physical Medicine and Rehab. 1 6 1 8 Plastic Surgery 3 3 Psychiatry 1 11 1 13 Public Health/Gen. Prev. Med. 1 2 1 4 Radiation Oncology 2 1 3 Surgery 7 1 8 Thoracic and Cardiac Surgery 3 3 Urology 1 1 1 3 Vascular Surgery 0 Other (e.g. Hospitalist, Admin) 1 8 1 10 None Listed or Unknown 1 6 7 Total: 3 9 1 1 17 0 3 1 261 8 37 14 355


43

Physician Primary Area of Practice by County - Oregon Border

Clackam

as

Clatsop

Colum

bia

Gilliam

Hood R

iver

Morrow

Multnom

ah

Sherman

Um

atilla

Wallow

a

Wasco

Washington

Total

Aerospace Medicine 0 Allergy and Immunology 0 Anesthesiology 1 9 2 12 Clinical Biochemical Genetics 0 Clinical Cytogenetics 0 Clinical Genetics 0 Clinical Molecular Genetics 0 Colon and Rectal Surgery 0 Dermatology 1 2 3 Diagnostic Radiology 4 8 1 1 1 15 Emergency Medicine 4 4 Family Medicine 1 1 1 2 5 10 Internal Medicine 8 1 13 1 3 26 Medical Physics 0 Neurological Surgery 0 Neurology 1 3 4 Neurology-Qualif. in Child Neur. 0 Nuclear Medicine 0 Obstetrics and Gynecology 2 3 5 Occupational Medicine 1 1 2 Ophthalmology 3 8 11 Orthopaedic Surgery 2 1 1 2 6 Otolaryngology 1 1 2 Pathology - Anatomic 0 Pathology - Clinical 0 Pathology - Anatomic/Clinical 3 3 Pediatrics 3 10 2 15 Physical Medicine and Rehab. 1 3 4 Plastic Surgery 0 Psychiatry 2 1 3 3 9 Public Health/Gen. Prev. Med. 1 1 Radiation Oncology 2 2 Surgery 1 4 3 8 Thoracic and Cardiac Surgery 1 1 Urology 1 1 1 3 Vascular Surgery 1 1 Other (e.g. Hospitalist, Admin) 2 2 None Listed or Unknown 3 1 4 Total: 29 2 1 0 4 0 81 0 3 0 1 32 153


44

Physician Primary Area of Practice by County - Idaho Border

Benew

ah

Bonner

Boundary

Kootenai

Latah

Nez Perce

Total

Aerospace Medicine 0 Allergy and Immunology 0 Anesthesiology 1 1 Clinical Biochemical Genetics 0 Clinical Cytogenetics 0 Clinical Genetics 0 Clinical Molecular Genetics 0 Colon and Rectal Surgery 0 Dermatology 1 1 Diagnostic Radiology 0 Emergency Medicine 1 1 2 Family Medicine 2 1 3 Internal Medicine 1 5 1 4 11 Medical Physics 0 Neurological Surgery 1 1 Neurology 0 Neurology-Qualif. in Child Neur. 0 Nuclear Medicine 0 Obstetrics and Gynecology 1 1 Occupational Medicine 0 Ophthalmology 0 Orthopaedic Surgery 1 1 Otolaryngology 1 1 Pathology - Anatomic 0 Pathology - Clinical 0 Pathology - Anatomic/Clinical 0 Pediatrics 1 1 Physical Medicine and Rehab. 0 Plastic Surgery 1 1 Psychiatry 2 2 Public Health/Gen. Prev. Med. 0 Radiation Oncology 1 1 Surgery 0 Thoracic and Cardiac Surgery 1 1 Urology 2 2 Vascular Surgery 0 Other (e.g. Hospitalist, Admin) 1 1 None Listed or Unknown 0 Total: 0 3 0 14 4 10 31


45

Secondary contact via email Week the census was emailed

License renewal print dates

Active with no census returned

With email address

Total emails sent

Total responses

Return rate

June 18-22

March 19-30

289 167 22 9 40.9%

June 25-29

April 9- May 3 494 172 46 6 13.0%

July 2-6 May 7-11

0 8 7 1 14.3%

July 9-13

May 14-18

0 5 5 2 40.0%

July 16-27

May 21-25 487 127 102 24 23.5%

July 30-Aug 3

May 29 - June 1

0 2 1 0 0.0%

Aug 6-10

June 4 - 8 213 73 62 12 19.4%

Aug 13-17

June 11 - 15

0 3 1 0 0.0%

Aug 13-17

Feb 15 - Apr 17

987 223 182 47 25.8%

Sep 10-14

June 18 - 22 228 80 68 14 20.6%

Sep 17-21

June 25- 29

0 2 2 0 0.0%

Sep 24-28

July 2 - 6

254 74 64 27 42.2%

Oct 8-12

July 16-20

265 75 68 10 14.7%

Oct 29-Nov 2

July 30 - Aug 3

224 88 77 14 18.2%

Totals: 3166 972 707 166 23.48% Practitioners that did not return a census form and have a listed email address are contacted. They are provided with a PDF copy of the census to complete. Secondary contact email messages are sent approximately four weeks after their license is renewed. Response rate increase: 3.81%


46

Appendix E: Performance Measures Defined

The licensing of allopathic physicians and physician assistants is a complex and specialized process, requiring interaction with entities all over the world and many primary source documents sent directly to Commission staff for review and verification. This measure tracks how quickly the credentialing unit of the Commission issues licenses on applications considered complete and ready for review. Due to a change in the licensing database in 2008, the only available data is from fiscal year 2009 forward. The target for this measure is 95 percent. Since the start of the pilot in fiscal year 2009, the Commission has maintained a performance of 99 percent or better in this measure.

Measure 1.1: Health care credentials issued within 14 days of receiving all documents.

COMPARISON GROUP FY 2010 FY 2011 FY 2012 Credentials

Issued % in

timelines Credentials

Issued % in

timelines Credentials

Issued % in

timelines MQAC 2,135 95% 2,266 99% 2,203 100%

NQAC 7,612 96% 9,080 95% 12,354 100%

Other HSQA Boards and Commissions

9,400 58% 7,053 67% 6,102 73%

HSQA Secretary Professions 33,976 23% 20,568 44% 17,831 45%

Table 1.1 Number and annual percentage of credentials issued meeting Performance Measure 1.1

20%

30%

40%

50%

60%

70%

80%

90%

100%

FY09 FY10 FY11 FY12

Licenses Issued Within Timelines

Secretary

HSQA

MQAC

NCQAC

mtm1303

Typewritten Text


47

The Medical Commission licenses the majority of applicants without issue or delay. However, if an applicant does not meet the requirements or has a history of unprofessional conduct or impairment, the Commission must decide whether to approve, deny, or grant the license with conditions. Once this decision is made the applicant must be notified within 30 days. The Commission has maintained a 100 percent performance for the past two years in this measure.

Measure 1.2: Percent of applications in which a notice of decision on application is issued within 30 days of the decision of the disciplinary authority to deny the license or grant with conditions.

COMPARISON GROUP FY 2010 FY 2011 FY 2012 NOD Issued

% in timelines

NOD Issued

% in timelines

NOD Issued

% in timelines

MQAC 10 90% 8 100% 2 100%

NQAC 1 0% 11 91% 25 100%

Other HSQA Boards and Commissions 34 56% 56 45% 69 77%

HSQA Secretary Professions 267 57% 263 56% 157 92%

Table 1.2 Number of notices of decision (NODs) issued in fiscal years 2010, 2011 and 2012 and percent issues within 30 days meeting Performance Measure 2.1.

0%

20%

40%

60%

80%

100%

FY09 FY10 FY11 FY12

Notices of Decision Issued Within Timelines

HSQA BC

Secretary

MQAC

NCQAC


48

Commission staff enters each complaint into the licensing database, summarizes the complaint, and places it into an electronic packet in preparation for the weekly case management team (CMT) meeting. At the weekly CMT meeting a panel of four Commission members assess each complaint and vote to close or authorize an investigation. The performance target for this measure is 77 percent.

Since the pilot began the Commission meets the timeline 99 to 100 percent of the time. The Medical Commission’s high performance is due to regaining the complaint intake functions when the pilot began in 2008. Since that time, the Medical Commission has consistently maintained a performance of 99 percent or better in this measure.

Measure 2.1-Percent of cases in which the intake and assessment steps are completed within 21 days.

Table 2.1 -Percent of cases in which the intake and assessment steps are completed within 21 days during fiscal years 2004 through 2012.

50%

60%

70%

80%

90%

100%


Complaints Assessed within 21 days

Secretary

HSQA

MQAC

NCQAC

Intake & Assessment Steps Completed within 21 Days

MQAC NCQAC Other HSQA Boards /

Commissions

Secretary Professions

Pre-Pilot Performance (FY 2004-2008)

83.1% 97.1% 88.1% 99.0%

Pilot Period Performance (FY 2009-2012)

99.5% 99.8% 76.1% 95.5%


49

The Medical Commission authorizes an investigation in approximately 70 percent of complaints. The Commission staff has 170 days to investigate the complaint and deliver the results to the Reviewing Commission Member (RCM). The RCM presents the investigations to the Commission. The Commission then decides the case and votes to close or take disciplinary action. The performance target for this measure is 77 percent. With the start of the pilot in fiscal 2009, the Commission immediately increased its performance. In fiscal year 2012 the Commission completed 92 percent of its cases within timelines.

Measure 2.2-Percent of cases in which the investigation step is completed within 170 days.

Investigation Step Completed within 170 Days

MQAC NCQAC Other HSQA

Boards / Commissions


Pre-pilot Performance (FY 2004-2008)

76.6% 69.5% 73.6% 79.5%

Pilot Period Performance (FY 2009-

2012) 86.9% 45.9% 71.5% 71.7%

Table 2.2 Percent of cases where the investigation step was completed within 170 days during fiscal years 2004 through 2012.

30%

40%

50%

60%

70%

80%

90%

100%


Investigations Completed within 170 days

Secretary

HSQA

MQAC

NCQAC


50

This measure tracks the progress the Medical Commission makes in reducing its backlog in the investigation step. The performance target for this measure is 23 percent.


The Commission dramatically reduced the investigations backlog in the first year of the pilot and effectively eliminated it by the end of fiscal year 2011. This improvement is due to specialized training, direct management, and focused investigations.


0%

5%

10%

15%

20%

25%

FY09 FY10 FY11 FY12

Backlog: Investigations older than 170 days

MQAC

0%

10%

20%

30%

40%

50%

60%

70%

Q1

FY 1

0

Q2

Q3

Q4

Q1

FY11 Q

2

Q3

Q4

Q1

FY12 Q

2

Q3

Q4

Cases in Investigations Over 170 Days

MQAC

NCQAC


Secretary


51

Investigation Step Exceeded 170 Days




FY 2010 Performance 4.9% 61.8% 25.9% 26.7%

FY 2011 Performance 6.3% 50.0% 23.4% 19.6%

FY 2012 Performance 2.5% 42.0% 13.5% 14.8%

Table 2.4 Percent of open currently in the investigation step that were over 170 days during fiscal years 2010, 2011, and 2012.

Measure 3.1 is a basic workforce efficiency measure comparing total investigations to the number of investigators employed by the Commission in a given month. While it is described at the number of investigations each investigator completes, in reality it is an average designed to measure the efficiency of the investigations unit as a whole. The Medical Commission has maintained historically high productivity in this measure. The Medical Commission does not feel that an average greater than 11 cases per investigator is a feasible workload to maintain while avoiding the burnout of personnel.

Measure 3.1: Number of completed investigations versus number of investigators.


52

The case disposition step runs from the end to the investigation to the beginning of the adjudicative process. The completed investigation file goes to a staff attorney and a reviewing commission member for review and presentation to the Commission. If the Commission votes to take disciplinary action, the staff attorney drafts the legal documents. If the Commission votes to issue formal charges, the draft charges go to the Office of the Attorney General for review and approval. This entire process, some of which the Commission does not have direct control, must be completed within 140 days or less. The performance target for this measure is 77 percent. The Commission has shown marked improvement in the last three years, culminating in completing this step on time in 92 percent of the cases in fiscal 2012.

Measure 2.3: Percent of cases in which the case disposition step is completed within 140 days.

Case Distribution Step Completed within 140 Days MQAC NCQAC

Other HSQA Boards /

Commissions


Pre-pilot Performance (FY 2004-2008) 79.4% 81.8% 73.6% 83.0%

Pilot Period Performance (FY 2009-2012) 87.0% 80.3% 73.3% 84.4%

Table 2.3 Percent of cases in which the case disposition step was completed within 140 days during fiscal years 2004 through 2012.

60%

65%

70%

75%

80%

85%

90%

95%

100%


Case Disposition Completed within 140 Days

Secretary

HSQA

MQAC

NCQAC


53

While in the case disposition step the Commission staff use this measure to track the progress of case disposition workload and those cases that have gone over timelines. The performance target for this measure is 23 percent. Since the start of the pilot in fiscal year 2009 the Commission has made steady progress in addressing the backlog of legal cases. Fiscal year 2012 saw an decrease in the performance of this measure, but quarterly reports of fiscal year 2012 show positive performance resuming.

The Medical Commission has seen a drop in this measure from over 40 percent to 20 percent, which was a first for all disciplining authorities being compared. By quarter four of fiscal year 2012, three out of four disciplining authorities had either met or come within several percentage points of the performance target. During the pilot period the Medical Commission has not added staff attorneys to its organization.

Measure 2.5: Percent of open cases currently in the case disposition step that are over 140 days.

Case Disposition Step Exceeded 140 Days




FY 2010 Performance 35.2% 49.4% 37.4% 54.6%

FY 2011 Performance 26.9% 36.1% 35.7% 45.4%

FY 2012 Performance 30.1% 28.0% 33.8% 36.0%

Table 2.5: Percent of open cases currently in the case disposition step that were over 140 days.

0%

10%

20%

30%

40%

50%

60%

70%

Q1

FY10 Q2

Q3

Q4

Q1

FY11 Q2

Q3

Q4

Q1

FY12 Q2 Q3

Q4

Cases in Case Disposition Over 140 Days

MQAC

NCQAC

Other HSQA Boards andCommissions

Secretary


54

Measure 3.2 is a basic workforce efficiency measure comparing total cases in the legal unit to the number of staff attorneys employed by the Commission in a given month. While it is described as the number of legal cases assigned each staff attorney, in reality it is an average designed to measure the efficiency of the legal unit as a whole. The Commission believes the target of 65 cases per staff attorney is too large a case load for medical cases and the complexities they entail.

Measure 3.2: Number of completed investigations that are assigned to a staff attorney for legal review or production of documents versus the number of staff attorneys.

50.939.9

0

20

40

60

80

100

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

FY10 FY11 FY12

Case

s

Comparison of Legal Caseloads

HSQA/NCQAC MQAC


55

The Department of Health created sanction guidelines in 2006. In 2009, the Legislature directed the Department to develop sanction rules to ensure consistent outcomes across professions. This measure is designed to measure the Commission’s compliance with the sanction rules. The performance target for this measure is 93 percent. The graph shows that once the Sanction Rules were in place the Medical Commission complied with the Sanction Rules in 99.2 percent of its orders.

Measure 2.6: Percent of Orders and STIDs that comply with the sanction schedule.

Final Orders or Stipulations to Informal Disposition Complying with Guideline Rule




Pre-Pilot Compliance with Guidelines (FY 2007-2008) 60.0% 84.8% 82.3% 97.0%

Pilot Period Compliance with Rules (FY 2009-2012) 99.2% 95.7% 90.7% 90.6%

Table 2.6: Percent of orders or stipulations to informal dispositions that comply with the sanction schedule during fiscal years 2007 through 2012.

65%

70%

75%

80%

85%

90%

95%

100%

2007 2008 2009 2010 2011 2012

Compliance with Sanction Schedule Guidelines/Rules

DOH Secretary

MQAC

NCQAC



56

The Commission has 14 days to transfer a complaint of sexual misconduct that does not contain clinical issues to the Secretary for disciplinary action. The performance target for this measure is 95 percent. The Medical Commission transferred 100 percent of their cases within one day of the decision to transfer, well within the 14 day timeline.

Measure 2.7: Percent of cases involving sexual misconduct where the board of commission determines it does not involve standard of care or clinical expertise and transfers it to the Secretary within 14 days.

MQAC NCQAC

Other HSQA Boards /

Commissions

Sexual misconduct cases identified 34 cases 33 cases 30 cases

Cases transferred to the secretary within 14 days

34 cases (100%)

33 cases (100%)

25 cases (83.3%)

Cases returned to board or commission due to clinical expertise or standard of care issues

7 cases (20.6%)

10 cases (30.3%)

3 cases (10%)

Table 2.7: Cases involving sexual misconduct where the board or commission determines it does not involve standard of care or clinical expertise and transfers the case to the secretary within 14 days, November 2008 through June 2012.

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

MQAC NCQAC HSQA Boards andCommissions

Percent of Sexual Misconduct Cases Transfered Within 14 Days November 2008 - June 2012

33 Cases 30

Cases

34 Cases


57

Measure 5.1 examines how effective the Commission is in its rulemaking process. The rules counted are standard rules that follow the three-stage rulemaking process. Performance is measured starting from the date of filing the CR-101 with the Office of the Code Reviser to the date the CR-103P notice is filed. The performance target for this measure is 75 percent or higher.

The Medical Commission enacted three rules prior to the pilot with two meeting the 18 month target and one falling outside the target for a total pre-pilot performance of 66.7 percent. During the pilot the Medical Commission completed the legislatively mandated pain rule within timelines for a 100 percent performance during the pilot.

Rules adopted based on fiscal year initiated, and Percent of adopted rules meeting Performance Measure 5.1

FY 2006 Pre-pilot

FY 2007 Pre-pilot

FY 2008 Pre-pilot

FY 2009 Pilot

Period

FY 2010 Pilot

Period

FY 2011 Pilot

Period

FY 2012 Pilot

Period

MQAC Rules 2 rules

100%

1 rule

0%

n/a n/a 1 rule

100%

n/a n/a

NCQAC Rules n/a 1 rule

100%

2 rules

50%

1 rule

100%

4 rules

100%

n/a n/a

Other HSQA Boards/Commissions Rules

16 rules

66.8%

6 rules

100%

11 rules

72.7%

4 rules

75%

9 rules

88.9%

1 rule

100%

1 rule

100%

Secretary Profession and Cross-Profession Rules

4 rules

50%

4 rules

100%

7 rules

89%

5 rules

60%

3 rules

100%

1 rule

0%

n/a

Measure 5.1: Percent of Rules in place within 18 months of filing a CR-101.


58

Management: Human Resources and Budget When an employee completes a probationary, trial service, annual review, or WMS review

performance period, the supervisor of that employee must submit performance assessments to the Office of Human Resources within ten calendar days. The performance target for this measure is 100 percent. During the measurement period, no disciplinary authority met the target of 100 percent. However, at 96 percent the Medical Commission performed the highest in this measure.

Measure 3.3: Percent of evaluations completed on time.

Two measures were developed to monitor programs’ budget management. The first compares spending to allotment, the second compares spending to revenue. The Commission reviews budget data on a quarterly basis with a goal that spending be less than revenue and allotment. All comparison groups spent less than their allotment and revenue.

Measure 4.1: Operating expenditure v. actual budget Measure 4.2: Revenue generated v. operating expenditures

93% 96% 94%

0%

20%

40%

60%

80%

100%

HSQA MQAC NCQAC

Percent of Evaluations On-Time

Evaluations overdue

0.0

0.5

1.0

1.5

2.0

2.5

Q1 Q2 Q3 Q4 Q1

FY11 FY12

$ Millio

ns

NCQAC

Revenue Allotment Expenditure

0.0

1.0

2.0

3.0

4.0

5.0

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

FY11 FY12

$ Millio

ns

HSQA Boards and Commissions

0.0

0.5

1.0

1.5

2.0

2.5

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

FY11 FY12

$ Millio

ns

MQAC

0.0

1.0

2.0

3.0

4.0

5.0

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

FY11 FY12

$ Millio

ns

HSQA Secretary Professions

0.0

0.5

1.0

1.5

2.0

2.5

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

FY11 FY12

$ Millio

ns

NCQAC


59

Appendix F: Aggregate Performance

In an effort to make the performance measures more transparent to the Commission members and staff, a simple aggregate measure has been created to gain a snapshot of overall performance. To generate this percentage, the performance measures relating to licensing, discipline, and rulemaking that are calculated in percentages are combined for the total actual performance. Measures related to human resources and budgets are not included in this calculation. This is divided by the total possible performance, which results in a percentage representing total aggregate performance. In the case of fiscal year 2012, the actual combined performance of the Commission is 851.64, with a total possible performance of 900. The resulting aggregate performance is 94.6 percent.

Case Timelines

The Medical Commission is aware that the agreed upon performance measures for the Pilot Project are a departure from the standard measurement of case timelines in the realm of medical regulation. Many state medical boards measure the full disciplinary process as opposed to single steps. A typical measurement is how many cases are resolved within 180 days of receiving the complaint. As part of the research efforts associated with this report and the Urban Institute research grant, Commission staff compiled information on closed cases from fiscal year 2002 through fiscal year 2012. In that time the cases resolved by fiscal year increased by 57.1 percent.

83.4% 83.9%

78.0%

56.8%

84.9% 84.5%

90.1% 93.3% 94.6%

50.0%

55.0%

60.0%

65.0%

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

FY 04 FY 05 FY 06 FY 07 FY 08 FY 09 FY 10 FY 11 FY 12

Medical Commission Aggregate Performance


60

Between fiscal year 2005 and fiscal year 2008, the Commission resolved 72.1 percent of cases within 180 days. Between fiscal year 2009 through fiscal year 2012, the Commission resolved 82.4 percent of complaints within 180 days. Cases that require 361 days or more to resolve tend to be the most complex and resource intensive. Between fiscal year 2005 and fiscal year 2008, 9.2 percent of complaints took more than 360 days to reach resolution. Between fiscal year 2009 and fiscal year 2012, 6.4 percent of complaints took more than 360 days to reach resolution.

These data and the chart above would appear to support performance data indicating the period of functionalization beginning in fiscal year 2005 was detrimental to overall Commission performance. The data would also appear to support the hypothesis that an integrated structure not only benefits Commission performance, but a model with greater autonomy delivers greater performance than an integrated model with less autonomy. The timelines data, the performance data presented in the report, and the national research summaries all appear to support the hypothesis that greater autonomy in an integrated model results in higher performance in all areas. This performance occurred with increased case loads and minimal staffing increases.

965 1029

985 947 1007

1188 1220 1318

1177

1389

1512

800900

1000110012001300140015001600

FY 02 FY 03 FY 04 FY 05 FY 06 FY 07 FY 08 FY 09 FY 10 FY 11 FY 12

Number of Cases Resolved by Fiscal Year

80% 79% 80% 76%

74%

65%

75% 75%

82% 87% 88% 90%

60%65%70%75%80%85%90%95%

100%

FY 02 FY 03 FY 04 FY 05 FY 06 FY 07 FY 08 FY 09 FY 10 FY 11 FY 12 FY 13Q1

Case Resolution Timelines by Fiscal Year

0-180 days


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Appendix G: Defaults, Duplicate Cases, and Representation

Defaults A default case or order occurs when a licensee is notified of impending legal action on their license,

but instead of responding the licensee simply walks away from their license. The result is a quick and relatively easy disciplinary action on the license. Medical Commission licensees rarely default on their license. There are many reasons for this, but the most obvious is the reporting of a suspension to the National Practitioner Data Bank and the reciprocal suspension actions that would be taken by other state medical boards where the respondent is licensed. Alternatively, if the licensee was licensed only in Washington no other state would license them as a medical doctor until the discipline is resolved in Washington.

Over 700 default orders have been issued since the start of the pilot. Two percent of those 700 involved Medical Commission cases. The other 98 percent of default orders for all health professions in the Department of Health are the responsibility of one unit, the Office of Legal Services.

HCA 7%

LPN 6%

MD 2%

NAC 19%

NAR 26%

RN 17%

Pilot to Date Default Orders : 6/2012


62

Duplicate Cases In Medical Commission cases, there is one license holder to a license. A physician assistant or

someone holding a physician and surgeon license typically will not hold any other active licenses.

By contrast, the very nature of training pathways under the Nursing Commission (nursing technician to Licensed Practical Nurse to Registered Nurse to Advanced Registered Nurse Practitioner), guarantees that most licensees will have more than one license. One hundred percent of the 5,492 Advanced Registered Nurse Practitioners licensed in Washington are required to have both the ARNP license and the Registered Nurse license to legally practice. Other licensees, such as counselors, dentists and nursing assistants can have multiple licenses. If a case involves a licensee with more than one credential it does not represent a significant workload increase, but the increased case counts do represent an inflated workload measurement. In the Medical Commission discipline functions it is one license, one case.

Representation Due to the advanced level of training and increased income potential, most Medical Commission

licensees have greater resources than the licensees of other professions within the Department of Health. Medical Commission licensees typically retain legal counsel at the outset of an investigation. Commission cases are more difficult to investigate and prosecute because most attorneys vigorously defend physicians, resulting in additional resources expended by the Medical Commission investigative and legal units.


63

Appendix H: History of the Medical Commission

The territorial legislature in Washington passed a Medical Practice Act in 1881, eight years before Washington became a state. The Washington Territorial Governor at the time was William Newell, M.D., who entered politics after many years of medical practice, including serving as Abraham Lincoln's private physician. As governor of Washington Territory, Dr. Newell was a supporter of progressive legislation

regarding public health and vital statistics as well as laws that established medical examining boards to license physicians, surgeons and pharmacies. When Dr. Newell's term of office expired, he became closely involved with efforts to upgrade the quality of Washington's practitioners and served on the Washington State Medical Examining Board in the 1890s.

On July 4, 1889, 75 citizens including 43 Republicans, 29 Democrats, and three Independents met in Olympia to draft the new Washington State

Constitution. Among the delegates was a group of physicians who worked diligently for effective medical legislation for the new state. Article XX of the Constitution — requiring a board of health, bureau of vital statistics and regulations concerning medicine, surgery and pharmacy - passed on Aug. 12, 1889, with no dissenting votes and no amendments. The Washington State Medical Society, in an official resolution, commended the committee for its diligence, noting, "The State of Washington alone possesses a constitutional clause requiring medical legislation."

The 1890 Medical Practice Act, which was a revision of the territorial legislation of 1881, created a nine-member Board of Examiners to determine applicant competency by administering a scientific and practical exam in anatomy and physiology. Violation of the act brought a $50 to $100 fine or 10 to 90 days in jail. In 1894, only 12 out of 34 applicants passed the exam, despite possessing diplomas from reputable medical colleges.

The law was amended in 1901 to require proof of graduation from an authorized college with a three-year course in medicine. In 1905, the law was amended to require a four-year education. In 1919, practitioners were required to have a diploma from a school approved by the Association of American Medical Colleges and the AMA Council on Medical Education and Hospital, and show evidence of a one-year internship in a 25-bed hospital that included six weeks of maternity service.

In 1955, the Medical Disciplinary Board was established and located within the Department of Licensing along with the Board of Examiners. In 1971, physician assistants were licensed for the first time. The Medical Disciplinary Board and the Board of Medical Examiners moved in 1989 to the newly created Department of Health. Five years later, the legislature abolished both medical boards and created the Washington Medical Quality Assurance Commission with the authority to license and discipline allopathic physicians and physician assistants.


64

Appendix I: Reduction in Opioid Deaths in Washington

The Commission has been closely monitoring opioid death data as it is published. In 2010, a steep decline in opioid related deaths appeared to occur. While the Commission cannot directly credit the pain rules with this decline, the threat of the rules and the awareness brought by the media exposure of the problem certainly had an impact on the behavior of patients and providers.

0

5

10

15

20

25

30

35

Opi

oid-

rela

ted

Dea

th

Workers Compensation Deaths in Washington

Possible Probable Definite


65

In 2011, the State of Washington experienced a decline in the rate of opioid involved overdoses. While the death rate decreased the rate of hospitalizations increased. Several reasons have been suggested for the trends; among them are a broader awareness of opioid dangers among patients and practitioners. This awareness has been generated by media coverage, the pain rules, and a general better understanding of risks relating to opioid therapies. The increase in hospitalizations could be an indication of specialization or acquired skill, with the result of fewer deaths but those that did not die were hospitalized.

Anecdotally, the Commission has received feedback and appreciation for the framework of the rules relating to prescribing limits. There have been confirmed reports from major health care institutions around the state that significant opioid MED reductions have occurred with little to no negative impact on quality of care. Whether these changes in behavior resulted in the decreased death rate cannot be determined at this time.

December 6, 2012

The Honorable Christine Gregoire The Honorable Jay Inslee Washington State Governor Washington State Governor-Elect P.O. Box 40002 210 11

th Ave. SW

Olympia, WA 98504-0002 Olympia, WA 98501

The Honorable Karen Keiser The Honorable Eileen Cody The Honorable Randi Becker The Honorable Joe Schmick Senate Health & Long-Term Care Committee House Health Care & Wellness Committee P.O. Box 40466 P.O. Box 40600 Olympia, WA 98504-0466 Olympia, WA 98504-0600 Dear Governor Gregoire, Governor-Elect Inslee, Senators Keiser and Becker, and Representatives Cody and Schmick: The Federation of State Medical Boards (FSMB) is pleased to have the opportunity to support the quality improvement measures implemented by the Washington State Medical Commission pursuant to the pilot project made possible by 4SHB 1103. As the national non-profit organization representing the seventy (70) state medical boards of the United States and its territories, one of the many ways the FSMB seeks to promote excellence in medical regulation is by facilitating the widespread adoption of best practices. We believe that the passage of 4SHB 1103 in 2008 properly empowered the Medical Commission to improve its operations and we urge the permanent adoption of the principles contained therein. The FSMB has long recognized that state medical boards require proper organization and effective empowerment in order to successfully discharge their important responsibilities to the public. To guide the state boards as they seek to identify and implement appropriate policies that afford maximum protection to the public, the FSMB has developed a number of legislative policy documents and resources, including its Elements of a State Medical and Osteopathic Board which was developed to serve as a blueprint of the structure and function of a modern state medical board. The Elements details the powers, duties and protections that are basic to a state medical board’s structure and function. With respect to 4SHB 1033, the Elements provides that the Board should be empowered to determine its staff needs and to employ, fix compensation for, evaluate and remove its own full-time, part-time and temporary staff in accordance with the statutory requirements of the state in which it sits. The Elements further provides that the Board should develop and adopt its own budget. These provisions, and the Elements in its entirety, are intended to assure that each state board is properly authorized to evaluate its

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Typewritten Text

Appendix J: FSMB Letter of Support

existing structure and function to determine if its operations may be improved and when appropriate, revise those structures and functions accordingly. The Elements seeks to encourage the public, state legislators, medical boards, medical societies and others who have an interest in the regulation of the medical profession to reexamine existing practice acts as they relate to the composition, structure, functions, responsibilities, powers and funding of medical boards. The FSMB believes that the Washington State Medical Commission, in its pilot project, has engaged in the type of thoughtful deliberations that result in greater protection of the public. The Commission’s report to which this letter of support is an addendum puts the Commission’s achievements on full display by plainly illustrating the numerous ways the granting of increased authority has resulted in greater efficiencies and increased effectiveness in its operations. The FSMB hopes that your office recognizes the Medical Commission’s successes and responds by permanently empowering the Commission and staff to continue their important work in the most thorough and efficient means possible. Thank you in advance for your consideration. Best regards,

Humayun J. Chaudhry, DO, FACP FSMB President and CEO

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Typewritten Text

Appendix K: Regence Letter of Support